Request for Transfer of Records (Adelaide Health Care) – AHC-0013-05-PS (Version 2) Instructions

Enter the date on which the patient or authorised person signed to give consent for release of medical information.

Enter the patient or authorised person's handwritten or typed name to indicate they consent to the release of medical information to Adelaide Health Care.

Enter the full name of the parent or caregiver who is providing consent for the patient. Fill only if 'Patient Date of Birth' indicates patient is under 16.

Provide any additional details for the parent or caregiver, such as relationship to the patient, contact phone number, or other relevant contact information. Fill only if 'Patient Date of Birth' indicates patient is under 16.

Enter the patient's full name as it appears on their medical records (given names and surname).

Enter the patient's date of birth.

Enter the patient's full residential address, including unit/flat number if applicable, street, suburb, state and postcode.

Check this box to request that the patient's health summary be included in the transferred records.

Check this box to request that the patient's pathology results be included in the transferred records.

Check this box to request inclusion of other specific documents and write what to include on the provided line.

Check this box to request that all specialist letters relating to the patient be included in the transferred records.

Check this box to request inclusion of any additional relevant information not covered by the other options.

Check this box to request that the patient's X‑ray results be included in the transferred records.

Enter a short, specific description of any other medical records to be forwarded that are not listed (e.g., 'immunisation notes', 'allergy list', or 'physiotherapy reports'). Fill only if 'Other (specify)' is 'Yes'.

Enter the date the request for transfer of records is being made.

Enter the name of the clinic where the patient was previously treated, if known.

Enter the full name of the doctor or recipient to whom the records should be sent.

Enter the phone number for the recipient clinic or doctor, including area or country code if applicable.

Enter the fax number for the recipient clinic or doctor, including area or country code if applicable.

Check this box when you are returning records for item 701 and will provide the corresponding '701 Date' on the form.

Enter the date for the returned records corresponding to item 701 (Row 1) indicating the most recently billed/returned date for those records. Fill only if 'Row 1 (701) — 701 Date' is 'Yes'.

Check this box when returning records to indicate the most recently billed item code '703' applies, and write the corresponding date in the adjacent Date field.

Enter the most recently billed date for item code 703 to indicate the date to be recorded when returning the patient records. Fill only if 'Row 2 - 703 Date' is 'Yes'.

Check this box when you are indicating the most recently billed date for item 705 on the returned records (and then fill in the corresponding Date field).

Check this box when providing the most recently billed date for item code 707 (enter the date on the line next to the box).

Enter the most recent billed date for item code 707 associated with this patient's returned records. Fill only if 'Row 4 — 707 Date' is 'Yes'.

Check this box to indicate/return records for item codes 721 and 723 and enter the most recently billed date for those items in the adjacent Date field.

Enter the most recently billed date for item codes 721 and 723 as requested when returning records. Fill only if 'Row 5 - 721, 723 (Date)' is 'Yes'.

Check this box when returning records relating to billing/item code 900 (to indicate you are providing or requesting the most recently billed date for code 900).

Enter the most recently billed date for service code 900 to indicate the return-of-records date for that item. Fill only if 'Row 6 (900)' is 'Yes'.

Check this box when you are returning records that include the most recently billed date for item code 2712, and provide the corresponding date in the adjacent Date field.

Enter the date when the records for code 2712 (Row 7) were most recently billed or returned. Fill only if 'Row 7 - 2712 Date' is 'Yes'.

Check this box when returning records to indicate you are reporting the most recently billed date for item code 2715 (Row 8) and want that date filled in the adjacent Date field.

Enter the date of the most recently billed item for service code 2715. Fill only if 'Row 8 — 2715' is 'Yes'.