Transfer of Previous Records Request Form

REQUEST FOR TRANSFER OF PATIENT MEDICAL RECORDS

I/We wish to advise that I am / we are now attending Hills Family General Practice.

I/We would like to request the transfer of all patient files for those names listed below to be transferred to Hills Family General Practice.

Thank you.

Practice/Provider Contact Details

Doctor and/or Practice Name

Address

Ph:

Fax:

Email:

Patient Details

First name *

Surname *

Date of Birth *

First Name

Surname

Date of Birth

First Name

Surname

Date of Birth

First Name

Surname

Date of Birth

By signing this form, you confirm that:

Authorise Hills Family General Practice to request the transfer of my personal medical records on mybehalf. *

Please forward a copy of their full medical history, including relevant reports and letters. We use Best Practice software and would prefer the files in XML format. XML files can be emailed to admin@hillsfamilygp.net.au, or posted on a USB/disc. Please contact us, or Best Practice support, if you require information on how to complete this.

Signature *

Draw signature|Type signatureClear

Date *

If a parent or guardian has completed this form on behalf of a patient aged 14-17, I confirm the patient is aware
of this registration and provided informed consent