Privacy and confidentiality

Your Community Health protects your privacy and confidentiality, and complies with privacy legislation.

If you use our services, we collect your information so that we can give you quality healthcare.

The types of information we collect includes:

- Your name, address, telephone number, email, date of birth, gender identity and preferred language

- Your health information, such as information provided by a referring doctor

- Information about your past and present care and treatment

- Your next of kin or preferred contact person

- Your Medicare number, Health Care Card number and pension number (if applicable).

We may also collect personal information for responding to enquiries, requests for access to information and resolving any complaints.

Please tell us if there is information about you that you do not want collected or shared with our clinicians. This may change the care options available to you and we will work with you to decide how we can deliver appropriate care.

Our client information and privacy policy can be reviewed online. For an overview of the Victorian Department of Health Rights and Privacy Principles that we follow, click here.

Accessing your health information

For more information about accessing your health information or privacy legislation, please ask your clinician or contact the Quality, Safety and Risk Manager on (03) 8470 1111 or healthrecords@yourch.org.au.

You may also complete the form below, download a copy here, or pick one up from our health centres.

Please note: it can take up to 45 days to receive your health information.

Access to Health Records Form

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

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Date of birth

Notes

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?

For example, consultations may be required with individuals listed in your health records to facilitate access.

Please provide copies of two pieces of identification with your signature.

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

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

Who are you seeking access to documents for?

Myself
My child under 16 years of age
TA family member I have Power of Attorney for

Client 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

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Date of birth

Client's relationship to you

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

Yes
No
Do not know

Please provide proof that you have authority to act on behalf of the client

Drag & Drop Files, Choose Files to Upload

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?

Receive a photocopy of the record
Receive an electronic copy of the record
View the record at an appointment with your service provider

Do you require an interpreter?

Which service(s) do you want to access your records for?

Medical Services
Oral Health Services
Allied Health Services

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

All of the health record
Part of the health record

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

For example: doctor, lawyer, insurance company, Victoria Police, Department of Child Protection.

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

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 healthrecords@yourch.org.au. Information about our Privacy Policy can be found on our website: www.yourch.org.au.

I declare that, to the best of my knowledge, I have completed this form correctly and have consent to access these health records

Ticking ‘yes’ is like signing this form.

Acknowledgement of timeframe

I acknowledge that it can take up to 45 days to receive health records information

Your Health Starts Here

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