Application for Access to Health Care Records (Nepean Blue Mountains Local Health District) – NBMA-431 Instructions

Check this box if you will provide a passport as your Column A form of identification — one of the two required forms (you must also provide one form from Column B).

Check this box if you will provide a citizenship certificate as your Column A form of identification — one of the two required forms (you must also provide one form from Column B).

Check this box if you will provide a current driver’s licence as your Column A form of identification — one of the two required forms (you must also provide one form from Column B).

Check this box if you will provide a public service photo ID as your Column A form of identification — one of the two required forms (you must also provide one form from Column B).

Check this box if you will provide a social security card (photo) as your Column A form of identification — one of the two required forms (you must also provide one form from Column B).

Check this box if you will provide a tertiary education photo ID as your Column A form of identification — one of the two required forms (you must also provide one form from Column B).

Check this box if you will provide an employment photo ID as your Column A form of identification — one of the two required forms (you must also provide one form from Column B).

Check this box if you are providing a Birth Certificate (ID issued by the Registry of Births Death and Marriages) as your Column B form of identification.

Check this box if you are providing a membership card from an education institution, union/trade card, or professional body as your Column B form of identification.

Check this box if you are providing an employment ID without a photo as your Column B form of identification.

Check this box if you are providing credit or debit cards or pass books as your Column B form of identification.

Check this box if you are providing a Medicare card, pension card, or healthcare card as your Column B form of identification.

Check this box if you are providing recent utility bills as your Column B form of identification.

Check this box if you or your nominated representative will collect the requested documents in person from the facility.

Check this box if you want the documents posted to the address you have provided.

Check this box if you want the documents delivered on a physical USB storage device.

Check this box if you want the documents sent electronically via secure email (SFT‑Kiteworks or other encrypted delivery).

Enter a brief, itemised description of the documents that were provided to or obtained by the facility for this request (e.g., discharge summary, imaging report, copies of notes). Fill only if 'ID provided: Yes' is 'Yes'.

Enter the first line of details describing the documents handed to the applicant, including document names, dates, and any reference or page counts as needed.

Enter a continuation or additional details about the documents provided to the applicant, such as further document names, clarifying notes, or supplementary item information.

Enter the receipt number issued for the additional fee payment. Fill only if 'Additional fee paid' is provided.

Enter any additional fee amount paid related to this request.

Enter the receipt number issued for the fee payment. Fill only if 'Fee amount paid' is provided.

Enter the total fee amount paid for this request.

Check this box when the client has given consent for the release of their medical record.

Check this box when the client has not given consent for the release of their medical record.

Check this box when client consent is not applicable for this request (for example, consent is not required under the circumstances).

Check this box when the applicant has presented and you have verified acceptable identification as required by the form.

Check this box when the applicant has not provided any acceptable identification.

Enter the name or initials of the staff member who sighted the identification provided. Fill only if 'ID provided: Yes' is 'Yes'.

Enter the date by which the request or required action is due.

Enter the date the application or documents were received by the office.

Enter the patient’s Medical Record Number (MRN) exactly as it appears on their records.

Enter the name (and optionally employee ID) of the staff member who processed this request.

Enter the signature or printed full name of the person who collected the documents at pickup. Fill only if 'Pick up (Collect in person)' is 'Yes'.

Check this box when the requester only viewed the health record at the facility (no copies or documents were provided or removed).

Check this box when the requester did not only view the record (for example, documents were copied, provided, or removed).

Enter the date on which the record was viewed under the 'View record only' option. Fill only if 'View record only - Yes' is 'Yes'.

Enter the full name (and optionally position or staff ID) of the staff member who supervised the view-only access. Fill only if 'View record only - Yes' is 'Yes'.

Enter the date when the request was processed.

Enter the full name (and optionally position or staff ID) of the person who processed the request.

Enter the patient's title or honorific (for example: Mr, Mrs, Ms, Dr).

Enter the patient's date of birth.

Enter the patient's mobile telephone number, including country or area code if applicable.

Enter the patient's work telephone number or the main daytime contact number.

Enter the patient's home telephone number.

Enter the patient's full residential street address, including unit or apartment details if relevant.

Enter the patient's given name(s), including first and any middle names.

Enter the patient's family name or surname.

Enter the postcode for the patient's residential address.

Enter any previous or former names the patient has used (for example maiden or legal former names).

Enter the patient's email address for contact and correspondence.

Check this box if the patient is alive.

Check this box if the patient is not a minor (14 years of age or older).

Check this box if the patient is deceased.

Check this box if the patient does not lack mental capacity and can give consent.

Check this box if you are not the patient's parent or legal guardian.

Check this box if the patient lacks the mental capacity to give consent.

Check this box if there is no current custody or access order for the patient.

Check this box if you are not the legal guardian and do not hold an Enduring Guardianship for the patient.

Check this box if you are not the executor or administrator of the deceased estate.

Check this box if you are the patient's legal guardian or hold an Enduring Guardianship for the patient.

Check this box if the patient is a minor (less than 14 years of age).

Check this box if you are the patient's parent or legal guardian.

Check this box if there is a current custody or access order in place for the patient.

Check this box if you are the executor of the will or the administrator of the deceased estate.

Enter the date when the applicant signed the form.

Enter the full printed name of the applicant as their signature for this access request.

If the patient is a minor, provide relevant details such as the patient's age and the name and relationship of the parent or guardian authorising this request.

If the patient lacks the mental capacity to give consent, describe the nature of the incapacity and provide details of the person who can consent or any supporting documentation.

If you are the patient's parent or guardian, enter your full name and your relationship to the patient and any authority you hold to act on their behalf.

Enter the requestor's given name or names as they appear on official records.

Enter the requestor's workplace telephone number, including area code if applicable.

Enter the requestor's family name or surname as it appears on official records.

Enter the requestor's title or honorific (for example, Mr, Mrs, Ms, Dr).

Enter the requestor's home telephone number, including area code if applicable.

Enter the requestor's full residential address, including street number, street name, suburb and state.

Enter the requestor's mobile phone number including country or area code if needed.

State the requestor's relationship to the patient (for example: self, parent, legal guardian, spouse, solicitor).

Enter the requestor's date of birth.

Enter the postcode for the requestor's residential address.

Enter the requestor's email address for correspondence and contact.

Check this box when you want to request a copy of the patient's medical records.

Check this box when you are requesting a copy of the patient's discharge summary as part of your records request.

Check this box when you are requesting copies of clinical imaging, X‑ray or clinical photography records (the listed fee of $33.00 GST inclusive applies).

Check this box when you are requesting a Date of Attendance Letter for the patient (this item is listed as no fee).

Enter any fee information, reference or short note related to the Date of Attendance Letter request (for example: “No fee”, an amount, or brief instruction).

Check this box when you are requesting copies of Work Cover certificates or medical certificates (the form indicates fee rules — no fee if less than 12 months since attendance; fees apply if more than 12 months).

Check this box if you are requesting to view the medical records in person (appointment will be arranged; viewing only — no copies provided; photography/photocopying is prohibited).

Enter a short value to indicate you are requesting to view medical records for this application (for example: 'Yes', 'Request viewing', or a brief note confirming you want to view the records).

Enter the specific date or range of dates for which you want the health records (for example a single date, start and end dates, or a brief date range).

Briefly describe which documents or parts of the medical record you are requesting (for example: discharge summary, progress notes, imaging reports, pathology results, or specific clinic letters).

Check this box when you are requesting a 50% reduction in the application fee and have provided supporting documents (for example pension or health card).

Enter a clear, short description of the records or information you are requesting (for example: type of document, date range, specific events or departments), including any reference numbers or other details that will help locate the records.

Check this box if the question about mental health information does not apply to this request (for example, if the concept of mental health information is irrelevant to these records).

Check this box if the records you are requesting do not include any mental health information.

Check this box if the records you are requesting include mental health information and you want those mental health records released.

Enter the full name of the facility or hospital you are authorising to release the clinical records. Fill only if 'Section B - Q6: Patient lacks capacity to give consent (No)', 'Section B - Q2: Applicant is patient's parent/guardian (No)', 'Section B - Q7: Applicant is legal guardian/holds Enduring Guardianship (No)' is 'Yes' (any).

Enter the full name of the person or organisation who will receive the copy of the clinical notes (the applicant). Fill only if 'Section B - Q6: Patient lacks capacity to give consent (No)', 'Section B - Q2: Applicant is patient's parent/guardian (No)', 'Section B - Q7: Applicant is legal guardian/holds Enduring Guardianship (No)' is 'Yes' (any).

Enter the date when the client/patient/guardian/authorised representative signed this consent. Fill only if 'Section B - Q6: Patient lacks capacity to give consent (No)', 'Section B - Q2: Applicant is patient's parent/guardian (No)', 'Section B - Q7: Applicant is legal guardian/holds Enduring Guardianship (No)' is 'Yes' (any).

Enter the full name of the person giving consent (the client/patient, parent, guardian or authorised representative). Fill only if 'Section B - Q6: Patient lacks capacity to give consent (No)', 'Section B - Q2: Applicant is patient's parent/guardian (No)', 'Section B - Q7: Applicant is legal guardian/holds Enduring Guardianship (No)' is 'Yes' (any).

Enter the signature (typed full name) of the client, patient, guardian or authorised representative providing consent. Fill only if 'Section B - Q6: Patient lacks capacity to give consent (No)', 'Section B - Q2: Applicant is patient's parent/guardian (No)', 'Section B - Q7: Applicant is legal guardian/holds Enduring Guardianship (No)' is 'Yes' (any).