Freedom of Information (FOI) Application
Direct all enquires
to xxxxxxxxxx@xx.xxx.xx
PATIENT DETAILS
First Name
Last Name
Previous Name
Date of Birth
Email Address
Contact Number/s
Postal Address
Suburb
State / Territory
Postcode
If you are requesting your records, a copy of your current photo ID (eg Driver’s
License, Passport) with signature is required.
TICK IF YOU ARE REQUESTING ON BEHALF OF ANOTHER PERSON
Please provide your details:
First Name
Last Name
Email Address
Contact Number/s
Postal Address
Suburb
State / Territory
Postcode
Relationship to
Patient
AUTHORITY FOR A REPRESENTATIVE TO ACT
Please provide additional supporting documentation:
Copy of representative’s personal identification; and
Patient’s written authorisation below.
I, [name]
______________give permission and authorisation for my representative to
act on my behalf and have access to any information requested.
__________________________________ Patient Signature
_______Date
If there is no Authority please provide evidence of other legal documents e.g. Enduring
Power of Attorney, VCAT order, Appointment as Guardian etc.
If the patient is deceased, please provide:
• The written authorisation of the person’s senior available next of kin
• Proof the senior available next of kin is over 18 and,
• A copy of the death certificate.
For more information, please refer to our web page at
Freedom of Information (FOI) | The RMH
Page 1
Or contact us on (03) 9342 7224 during normal business hours
Freedom of Information (FOI) Application
Direct all enquires
to xxxxxxxxxx@xx.xxx.xx
DESCRIBE THE DOCUMENTS YOU ARE REQUESTING
Please tick
Date Range From
To
Discharge Summaries (where available provided at no cost)
Clinical Notes / Progress Notes
Includes Emergency Department notes, operation reports, anaesthesia records,
outpatients and mental health notes
Radiology Images (includes X-rays, CT scans, MRIs, Ultrasound, PET scans, etc)
Radiology reports
Outgoing Clinical Correspondence
Mental Health Assessments
Medication Records
Include records prior to 2016 (Paper History - stored offsite – attracts extra
charges)
You can give more detail here:
____________________________________________________________________________
____________________________________________________________________________
Form of Access: (
tick one)
Emailed
Secure document (preferred) OR
Posted Paper documents (incur extra charges)
All documents are reviewed in accordance with the Freedom of Information Act 1982 (Vic).
Some documents may require redactions. If you are not wil ing to receive a copy of a
redacted document, the document wil not be released, and the application denied.
Are you wil ing to receive redacted documents?
Yes OR No
For more information, please refer to our web page at
Freedom of Information (FOI) | The RMH
Page 2
Or contact us on (03) 9342 7224 during normal business hours
Freedom of Information (FOI) Application
Direct all enquires
to xxxxxxxxxx@xx.xxx.xx
FEES AND CHARGES
Application fee:
$32.70 (non-refundable)
Search and Retrieval fee (off-site):
$24.50
Electronic Medical Record pages (PDF):
$0.05 per page
Paper file (copied or scanned) pages:
$0.20 per page
Radiology Images (via link)
$22.00 per link
Medical Photography (USB):
$22.00 per USB
Printed records per page:
$0.20 per page
Postage charges:
$11.00 registered mail
Inspection / Supervision charge:
$6.10 per quarter-hour or part thereof
A valid application requires payment of the application fee. As your application is processed,
additional charges may apply calculated in accordance with the schedule listed above. If
additional charges apply, we wil invoice you as the request is processed.
If you have a Concession Card:
The application fee is waived if you provide details of your pension or healthcare card.
However, production (photocopying, CD, link etc.) costs may stil apply. Please ensure you
attach a copy of your pension or healthcare card to your request.
SIGN THE APPLICATION
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
have to supply proof of identification.
__________________________________ Applicant’s Signature _______Date
CHECKLIST FOR APPLICATION
Please ensure that you include the following with your application.
• This Application form with your signature
• A Copy of the Photo Identification
• Patient consent or proof of Senior next of kin (for applications by those who are not
the patient)
• Application fee
• Pension or Healthcare Card (if applicable)
Please email signed application form with proof of identification to xxxxxxxxxx@xx.xxx.xx
.
For more information, please refer to our web page at
Freedom of Information (FOI) | The RMH
Page 3
Or contact us on (03) 9342 7224 during normal business hours
Freedom of Information (FOI) Application
Direct all enquires
to xxxxxxxxxx@xx.xxx.xx
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
The Royal Melbourne Hospital
C/- Post Office
Royal Melbourne Hospital, 300 Grattan St PARKVILLE VIC 3050
Phone (03) 9342 7224 Fax (03) 9139 3000
Email
: xxxxxxxxxx@xx.xxx.xx
What is the Freedom of Information process?
Approval Process
Al health records undergo 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 email of our decision, usually within 30 days of receipt of payment of
the application fee (unless further time is allowed by the FOI Act).
For more information, please refer to our web page at
Freedom of Information (FOI) | The RMH
Page 4
Or contact us on (03) 9342 7224 during normal business hours
Document Outline
