  Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM

NSW Ministry of Health – GIPA Application
Government Information (Public Access) Act 2009
Please complete this form to apply for formal access to government information held by the NSW Ministry
of Health (only) under the Government Information (Public Access) Act 2009 (GIPA Act).
***IMPORTANT: This is not the application form to request access to medical records, or information
held by hospitals, local health districts, or health services as the NSW Ministry of Health does not
hold, or have access to these records.
Please contact your hospital, doctor, or local health district to apply for medical records or any other
information held by that agency.  See http://www.health.nsw.gov.au/lhd/pages/default.aspx to find your local
health district or health service provider.
To apply for access to information held by the Ministry of Health, please proceed with this form.  If you need
help in fil ing out this form, please contact the GIPA Team via email at: xxxxxxxx@xxxxxx.xxx.xxx.xx, or
visit our website at: http:/ www.health.nsw.gov.au/gipaa/Pages/default.aspx
1.  Your details

First name:
..........................................................................................    Title:………….

Last name:
…………………………………………… Date of Birth: ………………………

Postal address:
...................................................................................………………………

…………………………………………………………………………………….
State:
……………………………………………. Postcode:………….......................
Telephone number:     ……………............................................... .
Email:
.....................................................................................................................
    I agree to receive correspondence at the above email address
Note: Your application wil  not be valid unless it includes an Australian Postal address or email address
Organisation:
.....................................................................................................................

Type of applicant:
Member of Parliament   ☐
Media representative                      ☐
Private Sector Business ☐
Legal representative                        ☐
Patient / Former Patient ☐
Staff member / former staff member ☐
Member of public            ☐
Union / local interest group               ☐
Other                               ☐

  Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
2.  Government information

•  Your application wil  not be considered valid unless you provide enough details to enable the NSW
Ministry of Health to identify the information you are seeking (i.e. statements such as “including but not
limited to…” and “al  records held in relation to…” wil  likely result in an application deemed as invalid.)
•  Should your scope be too broad, and we considered that it is a diversion of our resources to process,
you wil  be contacted inviting you to amend and reduce the scope of your application.
•  You can only apply for access to information that is contained in records or documents that are
currently held by the NSW Ministry of Health, at the time the application is received.
•  The NSW Ministry of Health does NOT hold personal health information or medical records. To apply
for this information, you must apply to the health service where you received your medical care. See
http://www.health.nsw.gov.au/lhd/pages/default.aspx
•  For non-personal information concerning other agencies within Health, including Local Health Districts,
please apply directly to the respective agency for access to their information.
•  The NSW Ministry of Health cannot be required to create a new document to respond to your
application but may, if it is more administratively convenient, decide to do so (i.e. create a summary
document rather than to copy all source documents)
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…………………………………………………... (If you require more space, please attach additional pages)

To minimise processing time and cost to you, you may wish to limit the scope of your
application, by clarifying that you are only seeking information contained in certain records
held by the NSW Ministry of Health, such as:

      By date:                         …………………………………………………………………………
                                                           (i.e. only records created between X date and X date, or records created after x date)

                 By type:                         …………………………………………………………………………
                                                       (i.e. only external correspondence sent or received by the Ministry, and not any
internal working papers of the NSW Ministry of Health)

                 By location:                    …………………………………………………………………………
                                                        (i.e. only records held by a particular staff member, unit, department or branch)

                 Other:                            ….…………………………………………………………………..

Type of information you are seeking:
Personal
Other

  Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
3.  Have you applied to another agency for substantially similar information?

An applicant is required to inform the agency if they have previously sought substantially the same
information from another agency

Have you, at any time, applied for similar information from another agency? Yes / No (circle one)

           If YES, which agency? ……………………………………………………………

4.  Court/Legal Proceedings

An agency may refuse to deal with an access application if the agency reasonably believes the
applicant, or person acting in concert with the applicant, is party to current proceedings before a court
and able to apply to that court for the information.
☐ I confirm that no such proceedings are on foot with respect to the information requested in this
application, OR
☐ I confirm there are legal proceedings on foot with respect to the information requested in this
application

5.  Proof of identity only required when an applicant is requesting their own personal
or health information
When seeking access to personal information, an applicant must provide proof of identity in the form of
certified copies of one of the following documents.
*Please note that it must contain your photograph, current address and signature.

Australian driver’s licence with photograph, signature and current address

Current Australian passport

Other Identification with photograph, proof of signature, and current address details

*If you are completing this form on behalf of someone else, please attach evidence of your
authorisation to do so. An original signed authority by the applicant is required.

*Certified means that the document has been verified signed and dated by an authorised person (JP, doctor,
teacher, pharmacist, legal practitioner, Postmaster - Australia Post)
6.  Form of access
How do you wish to access the information?
   A copy of the document(s)

              Access in another way (please specify)
.........................................................................................................................................................
7.  Disclosure log
If the information sought is released to you and would be of interest to other members of the public,
details about your application may be recorded in the agency’s ‘disclosure log’. This is published on the
agency’s website. Note that personal information wil  not be published on our disclosure log.

Do you object to this?   Yes / No (circle one)

  Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
8.  Third party consent
If the information sought is of a kind that would require consultation with a third party (as required under
section 54 of the GIPA Act), your name may be disclosed to a third party.
•  Do you consent to this? Yes / No (circle one)
      ☐ I understand that not agreeing could affect the outcome of my application
9.  Personal information contained within documents
           We may remove personal information of other persons and, if appropriate, staf  names from documents.
•  Do you consent to this? Yes / No (circle one)
           *If NO is selected, we are required to consult with any third party whose personal information is contained in the records
10.  Processing fees

•  Under the GIPA Act, the application fee is $30.00 which, in a request for personal documents, covers
20 hours of processing.
•  Processing charges for non-personal requests are $30.00 per hour.
•  If it appears that it wil  take more than 4 hours to process and finalise your application, we may
request an advance deposit for 50% of the estimated processing charges, before continuing with the
application. The processing time to complete the application stops until payment has been received
by the NSW Ministry of Health.
•  Processing charges (not including the application fee) may be reduced by 50% if you are the holder of
a Pensioner Concession card issued by the Commonwealth that is in force, a full-time student,
applying for or on behalf of a non-profit organisation), or where a public interest is sufficiently
demonstrated.
•  Decisions on discounts to processing fees are not made until the decision is being finalised.

11.  Application payment

Please make the payment for the $30 GIPA application fee to NSW Ministry of Health by Visa or Mastercard
Credit/Debit card via our online payment portal by:
Option 1: Use QR Code
Scanning the QR Link to use a device to navigate to the online portal which wil  prefil
relevant information. Proceed to populate your information and complete payment.
Option 2: Click URL Link
Click here to navigate to the online portal which wil  prefil  relevant information.
Proceed to populate your information and complete payment.

Option 3: Type in web address
Navigate to: https://paynswhealth.health.nsw.gov.au/other-payments and select the
following:

Health Organisation = Ministry of Health
Hospital/Facility = Ministry of Health
Service: GIPA – Government Information (Public Access)
Important
•  Ensure you download, save, or email a copy of the payment receipt upon payment.
•  Provide a copy of your payment receipt with submission of this form or to email
MOH -xxxx@xxxxxx.xxx.xxx.xx.
•  Your application wil  require your $30 payment or a copy of the online payment receipt to be valid
•  There is no application fee waiver or discount.

Applicant’s signature: ....................................................................................
Date:  ……………….…

  Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM

INFORMATION FOR APPLICANTS

•  Please try to provide as much detail as you can to help us identify the documents you want.

•  You wil  be contacted within 5 working days after the application is received to notify you of
the agency’s decision as to the validity of your application.

Please note: An application is not valid if it is an application for excluded information of the
agency or does not comply with the formal requirements for access applications as per section 41
of the GIPA Act.

•  Your request wil  be dealt with as soon as possible and in any case within twenty working days after
it is registered. However, if an agency is obliged to conduct third party consultations, section 54 of
the GIPA Act provides for an additional 10 working days (up to a maximum of 15 working days,
unless an extension of time is required) in which to process the application.

•  If the documents you seek are more likely to be held by another Agency, your request wil
be transferred, and you will be notified.

GIPA Specialist
Please send this form
Corporate Governance & Risk Management
and the application fee to:
Legal and Regulatory Services
Locked Mail Bag 2030
St Leonards NSW 1590

Or via email at:  xxxxxxxx@xxxxxx.xxx.xxx.xx

Privacy Statement

Under the GIPA Act you must provide your name and address or email address and a description

of the information you seek access to.

If you do not provide all information requested, we may not be able to process your application.
Your details wil  be stored and managed in accordance with the Privacy and Personal Information
Protection Act 1998 and the State Records Act 1998.

Your information wil  not be used for any other purpose and wil  not be given to any other third
party except where required by law.

General information about the GIPA Act is available by calling The Information and Privacy Commission NSW on
Freecall 1800 472 679 Email: xxxxxxx@xxx.xxx.xxx.xx Website: www.ipc.nsw.gov.au.

Office use only:
Date application received:  ……………………………File reference:……………..……………………………………..

Document Outline