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 *

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.

I understand that:

This request is voluntary and that I may withdraw my consent prior to the transfer occuring.
My medical records 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.
My 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 my original medical records in accordance with legal and regulatory requirements, including mandatory retention periods under relevant state and Commonwealth legislation.
Transferring my records does not result in deletion of my records from the former Healthicare records.
WentWest (on behalf of the former Healthicare) may retain copies of transfer requests and related correspondence for administrative, legal, and audit purposes.
I may request access to my retained records in the future in accordance with applicable privacy laws.

Signature *

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Date *