APPLICATION
FOR A COPY MRN: 0308094
OF
CLINICAL NOTES LOG:
390 Victoria Street
DARLINGHURST NSW 2010
Phone:
8382 2306 / 8382 2130 Fax: 8382 2977 / 8382 2764
PATIENT
DETAILS:
Title: Mr / Mrs / Ms / Miss 0308094 Date of Birth:
______25 - 8 -70_____________
Given
Name (s): _______Alexander____________________ Surname: _____Bailiff____________________
Address
(At time of attendance to hospital): ____22 Talbot Place Woolloomooloo______________________
______________________________________________________________
Postcode: ____2011_________
Approximate
Date(s) of Attendance to Hospital:
_________________October - November______________
YOU’RE
REQUEST:
Please describe clearly if you require copies of
the entire medical record or only certain information:
__________________________________________________________________________________________
Section 52 of the Mental Health Act 2007
__________________________________________________________________________________________
Section 74 (3) and Schedule 3 Mental Health Act 2007
__________________________________________________________________________________________
Section 76 (1)(a) of the Mental Health Act 2007
Please
indicate the purpose for which the Clinical Notes are required:
__________________________________________________________________________________________
New South Wales Supreme Court Appeal against Community Treatment Order
__________________________________________________________________________________________
__________________________________________________________________________________________
If this application is to obtain the Clinical Notes
of someone other than you please complete the following section:
APPLICATION
DETAILS:
Title: Mr / Mrs / Ms / Miss Relationship to Patient: SELF________________________
Given
Name(s): _____Alexander________________ Surname:
____Bailiff_____________________________
Important:
i.
If you are submitting this request on the
behalf of another person, please have them personally sign the attached consent
form authorising the hospital to release the require information about you.
ii.
If you are submitting this request to obtain
information of a deceased person then a copy of the Death Certificate or Will
must be provided along with a signed consent from the Next of Kin or Executor
of the Will. The deceased’s Next of Kin or Executor of the Will must also
provide sufficient information to identify them, eg: a copy of driver’s
licence.
Fees
and Charges:
The
application fee for a copy of a patient’s Clinical Notes: $33.00 including GST, up to 80 pages 44 cents per page after 80 pages.
The application fee
of $33.00 should be submitted with this application form. (Applications will
not be processed until this
fee is received).
How
is this information to be made available ? (Please tick)
□ To be collected from the Medical Record
Department of St. Vincent's Hospital;
Name of person collecting the Clinical Notes:
______________________________________________________
NB Personal identification is required when
collecting the Clinical Notes.
□ To be posted to the following address:
_________________________________________________________________________________________
Your request
will be dealt with as soon as possible and in any case within 21-28 working
days after it is received.
So that your
application is processed in a timely manner please ensure that the following
are submitted with your application form;
1.
Application fee may be paid by cash (in
person only), a cheque payable to St. Vincent's Hospital or credit card.
CREDIT CARD HOLDER:
_________________________________________________ MASTER CARD / VISA
CREDIT CARD NUMBER: ___
___ ___ ___ / ___ ___ ___ ___ / ___ ___ ___ ___ /
___ ___ ___ ___
EXP DATE ____/____ 3 DIGIT VERIFICATION
NUMBER: ___ / ___ / ___
2.
Patient’s authority consenting to the
release of the Clinical Notes.
(Only required if the
application is being made on someone else’s behalf).
3.
Enclose photocopies
of two pieces of identity, as verification of the applicant’s identity.
eg: driver’s licence,
passport.
This
is to certify that the details on this form are correct to the best of my
knowledge. I understand that full
payment and appropriate identification are required before documents are
processed and released.
Signature of Applicant:
_______Alexander Bailiff___________________ Date: _____29/12/15___________
Contact Telephone Number:
_____04 3777 3777_________________
Contact E-mail:
______SaintAlexander@mail.com______________________________________
MRN:
_______0308094_______________________
Date
application received: _____________________________________________________________________
Has the application fee been paid:
_______________________________________________________________
Has the
correct authority been submitted: _________________________________________________________
Expected
date of completion:
___________________________________________________________________
Other:
_____________________________________________________________________________________
THIS APPLICATION
CANNOT BE PROCESSED WITHOUT THE SIGNATURE OF THE APPLICANT
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