DEPARTMENT OF HEALTH (WESTERN AUSTRALIA) 
 
APPLICATION FOR ACCESS TO DOCUMENTS 
 
(under Freedom of Information Act 1992, S. 12) 
 
DETAILS OF APPLICANT 
 
Surname:   ...................................................................................................................................  
 
Given Names:   ............................................................................................................................  
 
Australian Postal Address:   .........................................................................................................  
 
Suburb:…………………………………………………………..  State:…………….. 
 
Postcode: .................. Telephone Number(s):……………………………..Fax:……………………….  
 
Name of Organisation/Business:   ...............................................................................................  
(If application is on behalf of an organisation) 
 
 
DETAILS OF REQUEST 
  Personal 
  Non-Personal   (Please tick) 
 
Personal applications are free from all fees and charges. 
 
I am applying for access to document(s) concerning  (Attach further pages if required) ...........................  
 
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FEES AND CHARGES 
 
Attached is a cheque/cash to the amount of $30.00 to cover the application fee.  I understand 
that before I obtain access to documents I will be required to pay processing charges in respect 
of this application and that I may be required to pay a deposit of 25% of the estimated cost of 
processing.  An estimate of charges can be supplied upon request. 
 
In certain cases a reduction in charges may apply - see section on fees and charges on the 
back of this form.  If you consider you are entitled to a reduction, submit a request with copies 
of documents which address the criteria on the back of this form and support your application 
for a fee reduction. 
 
Please make cheques out to “Freedom of Information – Department of Health”. 
 
I am requesting a reduction in fees and charges 
  Yes 
  No 
(Please tick) 
 
 
APPLICANTS SIGNATURE: .........................................................  
Date  ........./.........../......... 

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ACCESS TO INFORMATION NOTES 
 
 
Applications 
 
 
Please provide sufficient information to enable the correct document(s) to be identified. 
(If seeking medical record information please provide Date of Birth). 
 
 
The agency may request proof of your identify. 
 
 
If you are seeking access to a document(s) on behalf of another person, the agency will 
require authorisation for you to act as an agent, in writing. 
 
 
Your application will be dealt with as soon as practicable (and in any case, within 45 
days) after it is received. 
 
 
Further information regarding your application can be obtained from the Co-ordinator on 
9222 6412.  The Freedom of Information Act 1992, is available for purchase from the 
State Law Publisher, 10 William Street, Perth (Telephone 6552 6000). 
 
Forms of Access 
 
You can request access to documents by way of inspection, a copy of a document, a copy of 
an audio or video tape, a computer disk, a transcript of a recorded document or of words 
recorded in shorthand or encoded form, or a written document in the case of a document from 
which words can be reproduced in written form.  Where the agency is unable to grant access in 
the form requested, access may be given in a different form. 
 
Personal Information 
 
Applicants seeking access to personal information about themselves will be required to show 
proof of identity before access is given to documents containing personal information. 
Applications for personal information are free of fees and charges.   
 
Fees and Charges 
 
Under section 12 (1) (e) of the Act an application fee is payable for access to non personal 
documents.  Under section 16 (1) a charge is payable for the time taken to process non-
personal applications. Cheques may be made payable to “Freedom of Information – 
Department of Health”.  
 
Application Fee: 
 
$30.00 
Processing Charge:   
$30.00 per hour 
Photocopying: 
 
$00.20 per copy 
Postage, delivery: 
 
Actual cost 
 
The charge payable under section 16 (1) (g) may be reduced by 25% if the applicant is the 
holder of a currently valid Commonwealth pensioner concession card or a concession card 
under the Rates and Charges (Rebates and Deferments) Act 1992. 
 
Lodgement of Applications 
 
Applications may be lodged  
 
By post, addressed to 
 
FOI Co-ordinator 
Level 1, B Block 
 
Department of Health WA 
PO Box 8172 
 
Perth Business Centre  WA  6849 
 
 
 
 
 

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