FREEDOM OF INFORMATION FORM FOR ACCESS TO DOCUMENTS

Patient Details
Mr/Mrs/Miss/Ms/Dr   Surname:………………………………..…….Given Names:…………………………….……………...
Surname at the time of admission/episode (if different from above):………………………………………………………….
Date of Birth: …………………………….... Phone number(s): (H)………………..……….. (M)………..……………….……
Address:………………………………………………………………………………………………………….……………………
Suburb:. ........................................... State:………………Postcode:……………….. Email:............... ..............................
Are you applying for information about another person?
Yes / No (please circle)
If yes, please describe your relationship to this person:………………….…….………and complete your details below

Applicant Details:
Mr/Mrs/Miss/Ms/Dr   Surname:…………………………………..…….……….Given Names:…………………..……………..
Phone number(s): (H)…………………………………………………….. (M)………………………………....…………………
Address:……………………………………………………………………………………………………………. …………………
Suburb:. ........................................... State:………………Postcode:……………….. Email:............... ..............................
If you are applying in respect to someone else, you must provide consent from the patient or identification
which clearly shows that you are the senior next of kin to the patient e.g. birth certificate, marriage certificate
or death certificate in addition to providing personal identification. If you are not the senior next of kin, you
must provide written authorisation from the patient  or  senior  next of kin permitting you to access the
information.

Common documents in a medical record are:
•  Discharge Summaries
•  Medication Records
•  Emergency Department notes
•  Operation Reports
•  Progress Notes
•  Anaesthetic Records
•  Care Plans
•  Mental Health notes
•  Observation Charts

Details of Request:
Describe clearly the documents you wish to access (include dates, location, subject matter or any other information
which would help identify the document(s))……………………………………………........................................................
………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
……………………………………………………………..………………………………………………………………………
Form of Access: (please circle one)
I wish to inspect the document(s)

Yes
No
I wish a copy of the document(s) on paper

Yes
No
I wish a copy of the document(s) to be emailed to me
Yes
No
I require copies of the Radiology Images

Yes
No
Some documents you require may need to have some information edited according to the Freedom of Information Act 1982
(Vic).  If you are not wil ing to receive a copy of an edited document, the document wil  not be released.
Are you wil ing to receive edited documents?

Yes
No

Please note: Our records are stored as part of the Parkvil e Precinct Electronic Medical Record which includes information
from Royal Women’s Hospital, Peter MacCal um Cancer Centre & Royal Children’s Hospital. By default, information from
other health services wil  not be included in your release. If you require further information from any of the other Precinct
partners, please contact them directly.
If you require further information please contact the Freedom of Information Officer on (03) 9342 7224 during normal business hours

Fees and Charges:
I understand that charges may apply under the Freedom of Information Act 1982 (Vic) and that I wil  be supplied with
an invoice for applicable fees and charges. I also understand that I wil  have to supply proof of identification.
Concessional Information:
The application fee wil  be waived if you provide details of your pension or healthcare card, however production
(photocopying, CD, link etc.) costs may still apply. Please ensure you attach to your request a copy of your pension
or healthcare card.

Application fee:

$31.80 (non-refundable)
Inspection / Supervision charge:
$5.00 per quarter-hour or part thereof
Search and Retrieval fee (off-site):
$23.90 per hour or part thereof
EMR Pages:

$0.05 per page
Scanned Pages:

$0.20 per page
Radiology Images (via link)

$20.00 per link
Medical illustrations (USB):

$20.00 per USB
Postage charges:

$11.00 registered mail
  Applicant's signature:..................................................................................................Date:.........................................

Checklist information: Please ensure that the following is submitted.
Application form
Application fee
Copy of Photo Identification
Pension or Healthcare Card (if applicable)
Patient consent or proof of Senior next of kin (for applications by those who are not the patient)

Once your payment is received (or we agree to waive it) you may be sent an invoice for production costs. Please note that
initial payment is for the cost of the $31.80 application fee to start the process. You wil  subsequently receive an invoice for
payment of other charges, calculated in accordance with the schedule listed above.
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Payment:
Please do not send your credit card details via email – it is not a secure method of communication

 Cheque       Money Order     Credit Card – complete details below     Visa       MasterCard

Cardholder name:
Exp
/

Card number:

Signature:
  Amount $

Please return application and payment to:
ATT: Freedom of Information Officer Health Information Services
The Royal Melbourne Hospital
C/- Post Office
Royal Melbourne Hospital, 300 Grattan St
PARKVILLE VIC  3050
Phone (03) 9342 7224 Fax (03) 9342 8008
Email: xxxxxxxxxx@xx.xxx.xx

What is the Freedom of Information process?
Approval Process
All health records undergo an appropriate review prior to release. Approval for release wil  be sought only after that review,
applicable fees are paid and valid authority provided. If the medical records are not your personal records, you must include
the authority of the patient (or if deceased, their senior next of kin).

Notification of Approval
We wil  notify you by mail of our decision, usually within 30 days of payment of the application fee (unless further time is
allowed by the FOI Act).
If you require further information please contact the Freedom of Information Officer on (03) 9342 7224 during normal business hours

Document Outline