Patient Consent to Release or Transfer of their Health Information - Word & PDF Template Form

________
________

________

________
________
ABN: ________

RE: AUTHORITY AND CONSENT TO RELEASE OR TRANSFER OF HEALTH INFORMATION

To Whom It May Concern,

I am writing to provide ________ (the "disclosing party") with my express and informed consent to release or transfer (hereinafter "transfer") my personal and health information, as detailed below, in accordance with the Privacy Act 1988 (Cth), the Australian Privacy Principles set out in Schedule 1 to that Act, and any applicable State or Territory health records legislation including, where relevant, the ________.

My details are as follows:

Name: ________
Date of birth: ________
Medicare/health identifier (if applicable): ________
Address:
________
Contact telephone: ________
Contact email: ________

1. Information to be transferred

1.1 I consent to the transfer of the following personal and health information held by the disclosing party:

________

1.2 I acknowledge that the information described above may constitute "sensitive information" and "health information" within the meaning of section 6 of the Privacy Act 1988 (Cth), and I consent to its collection, use and disclosure for the purpose set out in clause 2.

2. Purpose of the transfer

2.1 I am providing this consent for the transfer of the above information for the following purpose only:

________

2.2 I understand that my information will not be used or disclosed for any purpose other than that stated in clause 2.1 without my further consent, except where such use or disclosure is required or authorised by or under an Australian law or a court/tribunal order.

3. Recipient of the information

3.1 I consent to the information being transferred to the following person or organisation:

Name of person/organisation: ________
Address: ________
Phone: ________
Email: ________
Relationship to patient: ________

4. Method of transfer

4.1 I request that the disclosing party use the following method to transfer my information to the recipient named in clause 3:

________

4.2 I acknowledge that I have been informed of the available secure methods of transfer and that I have selected the above method.

5. Duration of consent

5.1 This consent takes effect on the date of my signature below and remains valid until the earlier of:

(a) the date the disclosing party receives a written notice of revocation from me in accordance with clause 6; or
(b) the following expiry date (if specified): ________.

6. Right to revoke consent

6.1 I understand that I have the right to revoke this consent at any time by providing written notice to the disclosing party at the address shown above.

6.2 I acknowledge that any revocation will not affect, and will not have any retrospective effect on, any transfer or other action lawfully taken by the disclosing party before it receives my written revocation.

7. Access, correction and privacy rights

7.1 I understand that, under the Australian Privacy Principles, I have the right to request access to, and correction of, my personal and health information held by the disclosing party, and that I may make a complaint to the disclosing party and, if not satisfied, to the Office of the Australian Information Commissioner (OAIC) regarding the handling of my information.

7.2 I confirm that the disclosing party has, or will, make available its privacy policy describing how my information is managed.

8. Release and limitation of liability

8.1 To the extent permitted by law, I release the disclosing party, its officers, employees and agents from any liability arising from the transfer of my health information undertaken in good faith and in accordance with this consent.

8.2 I acknowledge that, once my information has been transferred to the recipient named in clause 3 by the method requested in clause 4, the disclosing party cannot control or guarantee the security, confidentiality or subsequent handling of that information by the recipient, and I accept the risks associated with the transfer method I have requested.

8.3 Nothing in this clause operates to exclude, restrict or modify any right, guarantee, condition, warranty or remedy that cannot lawfully be excluded, restricted or modified under the Competition and Consumer Act 2010 (Cth), including the Australian Consumer Law, or any other applicable law.

9. Acknowledgements

9.1 By signing below, I confirm that:

(a) the information set out in this document is true and correct;
(b) I am providing this consent freely and voluntarily, and I have not been subjected to any pressure or undue influence;
(c) I understand the nature, purpose and effect of the transfer of my health information; and
(d) I am at least 18 years of age, or where I am signing on behalf of the patient, I am lawfully authorised to do so.

10. Authorised representative (if applicable)

10.1 Where this consent is signed by a person other than the patient, that person's authority to act is as follows: ________.

11. Patient signature

Patient signature: ..........................................................................

Print patient name: ________

Date of signing: ________

Witness signature: ..........................................................................

Print witness name: ________

Witness phone: ________

Witness email: ________

Date witnessed: ________

OFFICE USE ONLY:

Received by: ..........................................................................

Date of receipt: ..........................................................................

Lorem ipsum dolor sit amet consectetur.

Lorem ipsum dolor sit amet consectetur.