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2 Royston Parade Asquith NSW 2077 02 9476 6307 Fax 02 9477 3591 REQUEST TO ACCESS MEDICAL RECORDS
1, .of .request access to or give consent to to access the entire contents of my medical record or the following documents ( see form A attached). I understand that the practice have the right to require that I attend a consultation to discuss the medical record. I have been advised of the fees applicable for such a consultation and that there will be no Medicare rebate for this service. I understand that I will not be permitted to remove the contents of my medical record from the premises of the medical practice, nor will I be permitted to alter or erase information contained in the medical record. I understand that I will be permitted to obtain copies of some or all of the contents of my medical record. Where copies are requested, a fee may be applicable. Further, I understand that copies may not be available at the time of inspection of my medical record and will be made available to me as soon as practicable following the inspection. Signature of the patient: . Date of Birth: .. Date .. Signature of the person given consent by Patient: .
Date: .
FORM A Documents to be accessed
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