Access to Medical Records

I am the patient Optional

I have been asked to act by the patient and have the patients written authorisation Optional

I have full parental responsibility for the patient and the patient is under the age of 18 Optional

a) has consented to my making this request, or Optional

b) is incapable of understanding the request Optional

I have been appointed by the court to manage the patient’s affairs and can produce on request a certified copy of the court order appointing me to do so Optional

I am acting in loco parentis and the patient is incapable of understanding the request Optional

I am the deceased person’s Personal Representative and can provide confirmation of my appointment on request (Grant of Probate/Letters of Administration) Optional

I have written, and witnessed, consent from the deceased person’s Personal Representative and can provide Proof of Appointment on request Optional

I have a claim arising from the person’s death Optional

Section 1: Patient Details

Section 2: Record Requested

Section 3: Details and declaration of applicant

Declaration

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