Hampton & South Medical Centre
General Practice · 4 Willis Lane, Hampton VIC 3188 · 03 9521 0352
Authorisation / Consent to Release Medical Records or Information
Instructions: Please complete all sections in full using a pen. Sign and date the form, then scan or photograph the completed form and attach it to your records request submission. This form will not be accepted without a signature.
Section 1 — Patient Details
Full name (as it appears on your records)
Section 2 — Type of Information Requested
Tick all that apply:
- Complete medical file
- Past investigation / test results
- Formal medical report
- Specialist correspondence
- Medication history
- Other (please specify below)
Additional details (time period, specific results, purpose of request, etc.)
Section 3 — Application on Behalf of Another Person
Complete this section only if you are requesting records on behalf of another person (e.g. as parent or guardian, or under a formal enduring power of attorney). You may be asked to provide evidence of your authority.
Your full name (applicant)
Your relationship to the patient
Section 4 — Declaration and Signature
I authorise Hampton & South Medical Centre to release the medical records or information described above. I understand that:
- A quotation will be provided before any documents or information are supplied.
- Fees may apply. Fees for records required for ongoing health care are prescribed by State Government Legislation (Victoria). Fees for records sought for insurance or legal purposes, and fees for formal medical reports, are not prescribed and are set at the discretion of the practice.
- This authorisation is valid for 90 days from the date of signing.
- This consent may be withdrawn in writing at any time prior to release of the records.