ࡱ> g bjbjVV xPr<r<l(TTThhh8$h?d>>>>>>>$~A0D>T|@>>RT>>z;2" >`1lbv=(>>0?-=DXDP >DT >|>>0?D :   Request for Access Form If you wish to apply to Western Region Health Centre to access/transfer your file, release your information to a third party or obtain information under the Health Records Act please complete this form. Information on access to information is overleaf. Please feel free to ask one of our staff members for assistance in completing this form or phone 8398 4100. 1. Details of ApplicantFamily Name: Given Name:Date of Birth:Your Address:Phone (home):Phone (mobile business): 2. Details of RequestIs this request to: ( Access health information ( Transfer my file to another health service provider eg GP Clinic, Community Health ServiceWhat information /document(s) do you want to access? P.T.O. 3. Form of Access YesNoI want to inspect the document(s)((I want a copy of the document(s)((I want the file / summary transferred to another service Provider((If yes, please give name and address of service:Other, please specify ((I understand that a fee may be charged regarding this request. Please sign here:  Date:  STAFF MUST PROVIDE CLIENT WITH A SIGNED COPY OF THIS FORM Staff name: ----------------------------------------------------------------- Staff signature: -------------------------------------------------------------- Date: ----------------------------------------------------------------------  Requesting Access to Western Region Health Centre Documents Information for Clients and the General Public The Request for Access Form can be used by clients to request access to health information held by Western Region Health Centre or have health information transferred to another health service provider or released to a third party holds which contains their personal and health information. Right to access your health information A client or their authorised representatives may request access to their health information. The decision as to whether or not to provide access to your health information will be based on legislation and the health privacy principles. Legislation mandates that Western Region Health Centre is not able to provide access to records if: it would constitute a serious threat to the life or health of any individual information was given in confidence by0 another person such as a friend or relative it would have an unreasonable impact on the privacy of others information interferes with legal proceedings denying access is required or authorised by law. Format to receive the information Access to client files or organisational documents can be in a number of ways: inspection of the information or, if the information is in electronic form, a print out of the information and have the opportunity to take notes, under the presence of a staff member the provision of a copy of the information the provision of an accurate summary, instead of a copy, if the organisation and the individual agree that a summary is appropriate or in the case of client files, an opportunity to view the record and accompanied by an explanation of the information by the health service provider. (Interpreter services may be utilised if necessary) Costs associated with the access to documents (Exemptions may apply) The act allows for reasonable costs to be collected in relationship to the access of files and include: Inspection of file in the presence of staff member - $5 per quarter hour, not exceeding $20. Copy of the file (copying and collating) - 20 cents per page, not exceeding $20. Summary of information -$25 per quarter hour, not exceeding $80. View record explained by service provider - as per a normal consultation fee. Client file / summary provided to other services free of charge. Release to a third party fees on application. When will you hear from us? Within 45 days of making the request you will be informed of the outcome of your request and be notified if the expected cost of access will be greater that $25. Correction of Information You have right to have information corrected if it is not up to date, incomplete or misleading. Any requests of this nature should be in writing, and in some instances supporting evidence may be required. Should corrections be made to client files, this will be done as required by legislation, as an attachment to the record.     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