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 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

Do you Have a Medicare Card?

Yes

Medicare Number

Reference Number

The number next to your name on Medicare Card.

Phone number

Patient Email

Address

Suburb

State

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

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

Clear

Full name of signatory

Relationship to patient if applicable (e.g. parent or legal guardian)

If you are human, leave this field blank.

Gynaecology

Infertility Medicine

Diagnostic & Surgical

Clinic Information