Department of Health
Credit Card Payment
Personal information collected by the Department of Health is handled in accordance with the
Information Privacy Act
2009.
The purpose of this form is so that you can make a credit card payment of the fees or charges associated with your access
application under the
Right to Information Act 2009.
Your personal information will only be used by authorised officers of the Department’s Privacy and Right to Information
Unit and Finance Branch in order to process your payment and provide correspondence in relation to your access
application. Your personal information will be securely stored and not disclosed to other third parties without your
consent unless required or authorised by law.
For information about how the Department of Health protects your personal information, or to learn about your right to
access your own personal information, please email RTI‐xxxxxxx@xxxxxx.xxx.xxx.xx or phone 07 3082 0546.
Right to Information Reference number:
Mastercard
Visa
Card number
Security Code
| | | | | | | | | | | | | | |
| |
Amount
Expiry date
$
/
Cardholder’s name
Telephone contact
Cardholder’s signature
Date
/ /
Return to:
Privacy and Right to Information Unit
Department of Health
GPO Box 48
BRISBANE QLD 4001