Request to Transfer Medical Records

This form is to be completed by the receiving practice to facilitate the secure transfer of a patient’s medical records from the former Healthicare, where the patient has already:

Provided valid identification, and
Signed a consent form authorising the transfer

Patient First Name *

Patient Middle or Other Given Names

Patient Surname *

Patient Date of Birth

Patient Address

Street address

City

State

Postcode

Patient Email Address

Patient Phone Number *

Receiving Practice Details

First Name (Receiving Doctor): *

Surname (Receiving Doctor): *

Provider Number:

Name of Medical Practice (Receiving Practice):

Address of Receiving Doctor/Practice *

Street address *

City *

State *

Postcode *

Email (Receiving Medical Practice) *

Phone Number (Receiving Medical Practice): *

Secure Messaging Provider/ID (e.g. Argus, HealthLink):

Transfer Method *

Confirmation of Patient Consent

The patient has provided signed written consent for transfer of their medical records

The details provided match the patient’s consent documentation

The patient’s identity has been verified in accordance with practice policies

Upload Consent *

Browse

Acknowledgement & Authorised Person

The receiving practice acknowledges that:

Information received will be handled in accordance with the Privacy Act 1988 (Cth) and Australian Privacy Principles
The practice will securely store and manage patient information upon receipt
Any discrepancies or issues identified will be communicated to WentWest (on behalf of the former Healthicare) promptly

Staff Member First Name: *

Staff Member Surname *

Staff Member Email: *

Signature *

Draw signature|Type signatureClear

Date *