Medical Record Release Consent Form Medical Record Release Consent Form PATIENT DETAILSSalutation:*Select...DrMrMrsMsMasterMissPatient First Name:* Patient First Name Patient Last Name:* Patient Last Name Mobile Number:*Email address:* Date of Birth:* DD slash MM slash YYYY Address* Street Address Street Address 2 Suburb State Post Code Is patient under 15 years old?*If patient is under 15 years old, parent or guardian details must be provided.Select...YesNoPARENT OR GUARDIAN DETAILSCompulsory if patient is under 15 years old.Salutation:*Select...DrMrMrsMsMasterMissFirst Name:* First Name Last Name:* Last Name Mobile Number:*Email address:* Relationship to patient:*Select...Parent – MotherParent – FatherLegal GuardianStep-ParentGrandparentOthers (please specify)Relationship to patient: Others (please specify)*DETAILS OF AUTHORISED RECIPIENTPractice or Organisation Name:*Contact Person Name (If applicable):Phone Number:*Email address:* Address* Street Address Street Address 2 Suburb State Post Code MEDICAL RECORD REQUESTEDName of Treating Clinician in Mind Oasis Clinic:*Type of Medical Record Requested:*Choose all options that applies: Consultation Letter Other (please specify) Type of Medical Record Requested - Others (Please specify):*Date Range of Medical Record Requested - Specific Start Date:* DD slash MM slash YYYY Date Range of Medical Record Requested - Specific End Date:* DD slash MM slash YYYY Purposes of Medical Record Release:*Choose all options that applies: Continuity of Care Specialist Referral Personal Records Legal or Insurance Purpose Second Opinion Employment or Occupational Health Requirement School or Educational Support NDIS / Disability Support CONSENT TO RELEASEUpload your Driver License or Passport*To protect your privacy and prevent unauthorised access to your medical records, please upload a copy of a valid government-issued photo ID (e.g., driver licence or passport). We only accept PDF or JPG.Accepted file types: pdf, jpg, Max. file size: 10 MB.Additional Information (Optional):Consent* I hereby authorise Mind Oasis Clinic to release my medical records to the healthcare provider or third party stated in this form.Consent* I understand and accept that Mind Oasis Clinic can refuse to release medical records in certain situations, as outlined under the Health Records and Information Privacy Act 2002 (NSW) (HRIP Act). These reasons typically involve potential harm to the individual or others, privacy concerns, or legal requirements.Consent* I understand and accept the estimated processing timeframe for medical record release. Under the Health Records and Information Privacy Act 2002 (NSW) (HRIP Act), healthcare providers must respond to a request for access to health information within 45 calendar days. At Mind Oasis Clinic, our estimated processing timeframe for medical record release requests is within 14 calendar days from the date we receive the completed consent form, verification documents, and full payment of the administrative fee — whichever is received last.Consent* I understand and accept to pay the administrative fee for medical record release. Under the Health Records and Information Privacy Act 2002 (NSW) (HRIP Act), healthcare providers can charge a reasonable fee to cover the cost of providing access to medical records. At Mind Oasis Clinic, an administrative fee of $66 (GST inclusive) is charged for the process and release of your medical records. An invoice will be emailed to you. Medical records will not be released until verification and payment are completed.PhoneThis field is for validation purposes and should be left unchanged.
