Letter Requesting Access to a Patient's Data from a Medical Institution - Word & PDF Template Form Pro · AU-law

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Attention: ________
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RE: Request for Access to Personal (Health) Information – ________

Dear ________,

I am writing to ________ (the “Organisation”) to request access to the health information held by the Organisation in relation to the following individual (the “Patient”):

Full name: ________
Date of birth: ________
Residential address: ________
Medical record / patient number (if known): ________

1. Capacity in which this request is made

This request is made by the undersigned in the following capacity in relation to the Patient:

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Where this request is made on behalf of the Patient rather than by the Patient personally, the undersigned warrants that they are duly authorised to make this request as an “authorised representative” or “responsible person” within the meaning of the Privacy Act 1988 (Cth), and evidence of that authority is attached and identified as follows: ________.

2. Legislative basis for the request

This request is made under Australian Privacy Principle 12 (Access to personal information) contained in Schedule 1 to the Privacy Act 1988 (Cth), together with the obligations applicable to organisations that handle health information under Part IIIA and the National Health (Privacy) provisions and any applicable State or Territory health records legislation, including (as relevant) ________.

3. Information requested

I respectfully request that the Organisation provide access to the following personal and health information held in relation to the Patient:

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I request that the information be provided in the following format: ________, and delivered to the address set out above or to such other address as may be agreed.

4. Purpose of the request

The purpose for which access to this information is sought is as follows:

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This information is required for the following reason(s):

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5. Consent and confidentiality

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In accordance with the Australian Privacy Principles, I confirm that the consent of the Patient (or their authorised representative) to the release of this information has been obtained. A signed consent authorisation is enclosed with this letter and is dated ________.

6. Timeframe for response

I would be grateful if the Organisation could respond to this request within 30 days of receipt, being the period within which an APP entity is generally expected to respond under Australian Privacy Principle 12, or within such other timeframe as is reasonable in the circumstances.

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7. Fees and further requirements

Please advise whether any access charge applies and the basis for any such charge, noting that any charge must not be excessive and must not apply to the making of the request itself. Please also advise if any further forms, identification or supporting documentation are required to process this request, and I will provide these promptly.

8. Verification of identity

To assist the Organisation in verifying my identity and authority, I enclose the following: ________.

9. Contact

Should you have any questions or require any clarification in relation to this request, please do not hesitate to contact me using the details set out at the top of this letter.

Thank you for your attention to this matter and your cooperation in facilitating the proper and lawful handling of the Patient’s health information.

Yours faithfully,

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Enclosures: ________