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Medical Record/ Document Request
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Medical Record/ Document Request
Medical Record/ Document Request Form
Request for Medical Records or Results
Request Type
Please tell us what you would like a copy of (select one)
*
-- Please Select --
Results / Letters
Full Medical Record
Please provide details to help us identify what you are requesting
*
e.g. date of visit, test name, doctor’s name, or receiving provider. Please note that we can only release tests that the specialist ordered, not those of other specialists.
Patient Details
Patients Full name
*
Date Of Birth
*
Medicare Number
*
Reference Number
*
The number next to your name on Medicare Card.
Phone number
*
Patient Email
*
Address
*
Address
Address
Address
Suburb
Suburb
State
State
Postcode
Postcode
Receiving Party Details (Required if requesting transfer to another provider)
It is your responsibility to ensure these detail are correct.
Name of doctor or provider
Clinic or hospital name
Email
Fax number
Terms & Conditions
Terms & Conditions (results)
*
I understand that MIGYNAE will process this request within 30 days, in accordance with Australian privacy and health records legislation
I understand that identity verification may be required before release of any records
Terms & Conditions (full records)
*
I understand that MIGYNAE will process this request within 30 days, in accordance with Australian privacy and health records legislation
I understand that identity verification may be required before release of any records
I understand that a fee of $55 including GST applies to requests for a digital copy and $66 - $132 including GST for a hard copy, and MIGYNAE will contact me for payment before processing
I authorise MIGYNAE to release or transfer my medical records as outlined in this request
Signature
*
signature
keyboard
Clear
Full name of signatory
*
Relationship to patient if applicable (e.g. parent or legal guardian)
Submit
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