Authority to Release Medical Information

Authority to Release Medical Information

This form allows you to either:-

Authorise your GP/Medical Practitioner to release your medical information to Persona Health,

or

Authorise Persona Health to release your medical information to your GP/Medical Practitioner.

A copy of this completed form needs to be retained by both the Releasing Party and the patient. The patient needs to provide the original copy of this completed form to the Releasing Party who will then provide the medical records/reports and/or statements to the Receiving Party.
What would you like to do? *
N/A

Authorise your GP/Medical Practitioner to release your medical information to Persona Health.
Authorise Persona Health to release your medical information to your GP/Medical Practitioner.
Title
N/A
Your Surname *
N/A
Your Given Name(s) *
N/A
Your Date of Birth *
N/A

dd-MM-yyyy

You must be over the age of 18.
Your Mobile Number *
N/A
Your Email *
N/A
Mobile Phone *
N/A
This information is collected for verification purposes only, and is deleted immediately after.
Photo ID *
N/A
Upload file Capture image using webcam
Please upload photos of your driver's licence (both sides), passport or photo ID.
Medicare Card *
N/A
Upload file Capture image using webcam
Please upload a photo of your Medicare Card.
I hereby authorise the Releasing Party
Releasing Party
N/A

Persona Health
My GP/Clinic/Hospital/Medical Practitioner
Persona Health Pty Ltd
17/423 Church Street
Parramatta NSW 2150
Tel : 02 8000 1980
email: reception@personahealth.com.au
Name of GP/Clinic/Hospital/Medical Practitioner *
N/A

Include the doctor/contact name if possible.
Address
N/A

Address Line 1 City State Post Code
Email
N/A
Phone *
N/A
to provide medical records, reports and/or statements as required to the Receiving Party
Receiving Party
N/A

Persona Health
My GP/Clinic/Hospital/Medical Practitioner
Persona Health Pty Ltd
17/423 Church Street
Parramatta NSW 2150
Tel : 02 8000 1980
email: reception@personahealth.com.au
Name of GP/Clinic/Hospital/Medical Practitioner *
N/A

Include the doctor/contact name if possible.
Address
N/A

Required Address Line 1 Required City Required State Required Post Code
Email
N/A
Phone *
N/A
relating to my medical examination(s) and/or treatment on or about...
N/A

Please enter specific dates or treatments as necessary, or 'Everything' if you want all your medical information released.
Declaration *
N/A

By signing this form, you are giving your consent for the above-named Releasing Party to release your relevant medical information, reports and/or statements to the above-named Receiving Party.

I confirm the above is true and correct.
Signature *
N/A

E-Signature Field
Clear
Witnessed by:
N/A

First Name Last Name
Witness's Mobile Number
N/A
Witness's Signature *
N/A

E-Signature Field
Clear
Date and Time of Submission
N/A

dd-MM-yyyy HH:MM AM/PM

Authority to Release Medical Information

I hereby authorise the Releasing Party

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