AUTHORITY FOR THE RELEASE OF PATIENT INFORMATION

For full information regarding your request and how DHSV manages your data, please see DHSV Guide to Client Information Privacy | www.dhsv.org.au

The following questions refer to the person making the request. The patient’s details (if different to the requestors) are to be listed on the next page.

First name: *

Last name: *

Address: *

Postcode: *

Contact number: *

E-mail address: *Please type "n/a" if you do not have an e-mail address

I am requesting information from: *

Royal Dental Hospital MelbourneSmile Squad School Dental Program

Who do you want us to send the records to? *

to another healthcare provider, e.g. doctor, dentist or other clinicto an individual, e.g. myself

No fee is charged to send your or your dependent's information, with your consent, to another dentist, doctor or clinic to assist in your or their continuing care.

A non-refundable fee of $31.80 (as of July 2023) must be paid and in addition other fees may be charged in respect to this request.

An exception can be made for people suffering financial hardship who may ask the Hospital to waive the application fee. Evidence can be uploaded at the end of this form.

Alteratively, you may contact us to discuss payment or fee waiver options with our Privacy Officer:

Email: privacy.officer@dhsv.org.au
Telephone: 03 9341 1013

You can change who you want to receive your information now and avoid any fees.

I, in the State of Victoria, authorise Dental Health Services Victoria to supply a copy of the following documents:

X-rays onlyClinical notes onlyPhotographs onlyThe entire clinical record held at DHSV (including x-rays, medical notes, correspondence & photographs)More specific request

relating to:

Patient's first name: *

Patient's last name: *

Date of Birth *

My relationship to the patient: *

selfparentother

If "other", please specify:

Dental record number (if known)

please forward the documents to the following person/company:

Clinician's / person's name: *

Clinic name / company: *

Clinic / company address: *

Clinic / company / person's e-mail address:

If more information is required, a staff member will be in touch regarding your request.

Your request is deemed an FOI request, in compliance with the Freedom of Information Act VIC 1982.

Once your request has been finalised concerning fees, you will receive a decision within 30 calendar days about the provision of your requested information.

Signature:

Draw signature|Type signatureClear

If you are requesting your personal information or personal records, you should provide proof of your identity, such as a driver’s license or other identification. To access the personal information of someone else, please provide proof of authority to do so. If you do not do this, DHSV may not be able to release the documents you have requested.

Photo identification (of the requestor)
Proof of authority to access, if applicable
Pensioner / Health Care Concession / DVA card, if in financial hardship

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