Front of hospital

Freedom of Information Online Application Form

Freedom of Information Application

Patient details

Info "Patient surname" is a mandatory field.
Info "Patient first name" is a mandatory field.
Info "Street address" is a mandatory field.
Info "Suburb/town" is a mandatory field.
Info "Postcode" is a mandatory field.
Info "Postcode" must be a 4 digit postcode.
Info "Phone" is a mandatory field.
Info "Phone" must be a number.
Info "Date of birth" is a mandatory field.
Info "Email address" is a mandatory field.
Info "Email address" must be a valid email address.

Applicant details (if different from above)

Info "Postcode" must be a 4 digit postcode.
Info "Email address" must be a valid email address.

For requests relating to children under the age of 16

Documents requested

E.g. discharge summaries, Emergency Department notes, clinical/progress notes, radiology and pathology results, correspondence and referral letters, medication records, observation charts, care plans, operation and anaesthetic records.

Info "Describe clearly the documents you wish to access (include date range, subject matter, types of documents):" is a mandatory field.

This will assist us to identify and locate documents relevant to your request.

Info "Reason for request" is a mandatory field.

Yes: the document will be released with any exempt material deleted and clearly marked. No: the document will be refused in full.

Info "Are you willing to receive edited documents?" is a mandatory field.
Info "Forms of access" is a mandatory field.
Info "Delivery of documents" is a mandatory field.

Authority to access information

You must provide signed authority from the patient to release their information or provide evidence that you have the authority to access this information. If a patient is a child under the age of 16 and there are legal circumstances that may impact on the release of the child’s information, evidence that you have the right to access the patient’s information must be provided (i.e. a copy of the Family Court Order).

Request for information relating to a deceased individual

Where the patient is deceased, the patient’s senior available next of kin must provide evidence that they are the next of kin (i.e. copy of the death certificate) and sign an authority to release the information if release is to a third party.

Payment of the application fee

Fees and charges

A $31.80 application fee (non-refundable) must accompany this form before the processing of this request can begin. For waiver of the application fee, please provide a copy of your valid Health Care Card or Pension Card or other evidence of hardship below.

Access charge

In addition to the application fee, the following access charges may apply. If applicable, you will be notified by mail of the relevant charges, which must be paid before you can access the documents. Do not pay these charges now. -Search charge of $23.85 per hour or part of (excludes requests relating to personal affairs of the applicant) -Viewing charge of $23.85 per hour, calculated per quarter hour or part of a quarter hour -Document charge of 20 cents per A4 page -Radiology on USB charge of $10 per USB (includes reports) -Registered mail charge of $11

Always quote - FOI and full patient name, and email remittance to [email protected]

Include photo identification that clearly shows your signature (e.g. driver licence or passport)

Info "Photo ID" is a mandatory field.