Consent to Transfer Medical Records

Please complete this form to authorise the secure transfer of your medical records to your new healthcare provider. Ensure all details are accurate to avoid delays in processing your request.

First Name *

Middle or Other Given Names

Surname *

Date of Birth

Address

Street address

City

State

Postcode

Email Address

Phone Number *

Family Member Details

Please complete these details below to authorise the secure transfer of your family members' (Under the age of 14 only) medical records to their new healthcare provider. Ensure all details are accurate to avoid delays in processing your request.

Full Name

Date of Birth

Full Name

Date of Birth

Full Name

Date of Birth

Full Name

Date of Birth

New Doctor & Medical Practice Details

First Name (Receiving Doctor): *

Surname (Receiving Doctor): *

Name of Medical Practice (Receiving Practice):

Address of Receiving Doctor/Medical Practice *

Street address *

City *

State *

Postcode *

Email (Receiving Medical Practice) *

Phone Number (Receiving Medical Practice): *

Secure Messaging ID (if applicable):

Consent Confirmation

I hereby request and authorise WentWest to transfer a copy of my medical records from the former Healthicare medical practice to the healthcare provider named above.

Where this request relates to a child or person for whom I am the parent, legal guardian, or authorised caregiver, I confirm that I have the legal authority to provide consent on their behalf and authorise the transfer of their medical records.

I understand that:

This request is voluntary and that I may withdraw my consent prior to the transfer occuring.
My medical records (or the records of the person on whose behalf I am providing consent) may contain sensitive information, including but not limited to mental health, sexual health, and other confidential health information.
This information will be transferred securely in accordance with applicable privacy laws, including the Privacy Act 1988 (Cth) and Australian Privacy Principles.
WentWest (on behalf of the former Healthicare) is not responsible for the use or handling of information once it has been received by the nominated practice.
Records will be transferred securely within 10 working days from the date of this request, where practicable.
I may be contacted if further identification or clarification is required.

I understand that:

WentWest (on behalf of the former Healthicare) will retain the original medical records in accordance with legal and regulatory requirements, including mandatory retention periods under relevant State and Commonwealth legislation.
Transferring records does not result in deletion of records from the former Healthicare records system.
WentWest (on behalf of the former Healthicare) may retain copies of transfer requests and related correspondence for administrative, legal, and audit purposes.
Access to retained records may be requested in the future in accordance with applicable privacy laws.

Patient/Parent/Guardian/Caregiver Name *

Signature *

Draw signature|Type signatureClear

Date *