Privacy and confidentiality - Your Community Health

Your Community Health protects the privacy and confidentiality of all clients and complies with privacy legislation.

If you access services at Your Community Health we will collect some information about you so that we can care for you in the best possible way.

We usually collect the following kinds of information:

Name, address, telephone number, email address, date of birth, gender identity and preferred language
Health information, including information provided by a referring doctor
Information about care and treatment, both past and present
Next of kin or preferred contact person
Medicare number, Health Care Card number and pension number (if applicable)

Personal information may also be collected for responding to inquiries, requests for access to information and resolving complaints.

If there is information about you that you do not want collected or shared with other health care workers, please tell us. This may change the care options available to you, so we will work with you to decide how to give you appropriate care.

Our client information and privacy policy is available for your information.

How you can access your health information

For more information about privacy and how to access your information, you can ask your health care worker or contact the Manager, Quality Safety and Risk on (03) 8470 1111 or email [email protected].

You may also complete the form below. You can download and print a hard copy here or pick one up from one of our health centres.

Access to health records form

Your details

We collect your details so we can respond to your application. We will only use your details for this purpose. Where your full details are not provided, your application for access to documents may be affected.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State Post code Country

Phone(Required)

Date of birth

Do you consent to Your Community Health disclosing your identity and knowledge of this application to other persons for any reasonable consultations necessary for processing your application?

Yes

For example, consultations may be with individuals who are listed in the health records you want to access.

Please provide a copy of your identification with a signature.

Max. file size: 50 MB.

For example, Australian Drivers Licence, Australian Passport, or a certified copy of your Medicare Care Card, Health Care Card, Pension Card or Veteran Card.

Are you seeking access to documents about yourself or other people?(Required)

Myself

Someone else

Client's details

We need to know whose health information you are seeking. We require proof that you have authority to access health information about another person.

Name

First Last

Address

Street Address Address Line 2 City State Post code Country

Phone

Date of birth

Client's relationship to you

Does the client know you are requesting access to their information?

Yes

Don't know

Please provide proof that you have authority to act for the person (client).

Max. file size: 50 MB.

For example, a will, Power of Attorney.

If the client is deceased, please provide details of their next of kin.

Details of the request for access or transfer

You have the right to access your health record and request correction to information. The decision to grant access will be based on legislation and the health privacy principles. For more information, please see 'Keeping your information private' and the 'Client Information Privacy Policy' on our website.

What is the reason for your request?

How would you like to access the health record?

View the record at one of our health centres

View the record with an explanation

Receive a photocopy of the record

Receive an electronic copy of the record

At which Your Community Health centre would you like to see the health record?

East Reservoir health centre (125 Blake Street)

Northcote health centre (42 Separation Street)

PANCH (Preston) health centre (300 Bell Street)

Do you require an interpreter?

Yes

What language?

Do you want access to all or part of the health record?

All of the health record

Part of the health record

Please clearly describe the information you require.

Do you want to transfer the health record to another organisation?

Yes

For example, a doctor, lawyer, insurance company.

Organisation or company name

Contact name

First Last

Address

Street Address Address Line 2 City State Post code Country

Phone

Next steps

We will assess your request in accordance with the Health Records Act 2001, and will contact you within 45 days of receiving this form. Costs may be associated with your request in line with the Health Records Act 2001. When we contact you, we will let you know if there are any costs. If you have any further queries or require assistance completing this form, please contact the Health Information Officer on (03) 8470 1111 or [email protected] Information about our Privacy Policy can be found on our website: www.yourcommunityhealth.org.au

I declare that to the best of my knowledge, I have answered correctly and have consent to access these health records.

Yes

Ticking 'yes' is like giving a signature on a form.

Comments

This field is for validation purposes and should be left unchanged.

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