Consent to Disclosure of Archived Mental Health Information to a Health Practitioner By
Full name of person applying for the mental health information
Name of the organisation at which the applicant provides health services.
Applicant’s telephone number, email and fax (in the event that further information is required) / Tel:
Email:
Fax:
Full details of the person to whom the information relates including any middle name, known maiden names, aliases and/or change of name (to assist searching)
Date of birth (if known) of person to whom the information relates
Gender of person to whom the information relates / Female Male
Other demographic information if known (e.g. most recent address)
If known, file or medical record/UR number, name of institution where the person formerly received mental health services, approximate dates of treatment or any other information which may assist retrieval of the records / File/medical record number:
UR number:
Name of institution:
Dates of treatment:
Other:
Please provide a full description of the information you are seeking (to assist searching).
If seeking specific documents or types of documents rather than the entire record please specify as this will reduce search times.
Address to which the requested information is to be delivered.
Note: the information will be delivered to the specified address in a secure bag addressed to the applicant.
Please cross out whichever option does not apply / I attach Consent Form 1 –consent of the person to whom the health information relates
I attach Consent Form 2 – Consent of the senior available next of kin
I am unable to obtain consent but apply for the information on the basis that I require it to provide health services to the person to whom the information relates.
Signature of applicant
Date:
As the applicant is not the person to whom the information relates Consent Form 1 (Patient Consent) Or Consent Form 2 (Consent of Senior available next of kin) must be completed and attached to this application, unless consent cannot be obtained and the disclosure of the information is required to provide health services to the person to whom the information relates in accordance with section 346(2)(f) of the Mental Health Act 2014.
Mental Health Act 2014
The Department of Health & Human Services holds these records as a former provider of mental health services. Section 346 of the Mental Health Act 2014 allows the disclosure of information about a consumer in a range of circumstances including if:
(a) the person to whom the health information relates consents to its disclosure;
(b) the person to whom the health information relates is deceased and the senior available next of kin of the person consents to its disclosure;
(c) the disclosure is required by another mental health service provider or a health service provider (within the meaning of section 3 of the Health Records Act 2001) to provide health services (within the meaning of section 3 of the Health Records Act 2001) to the person to whom the information relates.
1
Application Form - Access to archived mental health information by health practitioners