Patient Online Access to Medical Records

Patient Online Access to Medical Records

  • Patient Online Access to Medical Records

    This form is to request or remove access to your online medical records. You can also use this form to request amendments to entries within your medical record

     

    Please complete the appropriate section(s) below:

     

    1.      Patient Details (Mandatory)

    2.      Application to Access Online Medical records

    3.      Remove Access to Online Medical records

    4.      Application to Amend Medical Record Entry Details

  • Risk of coercion

    *Before completing this from, please think carefully before answering the question below*

    Is it possible that you (the patient) may come under pressure to give someone access to your personal information in your online health record against your will?

  • 1. Patient Details

    Date of Birth:
    For example, 15 3 1984

  • If the request is on behalf of the patient, please provide your details below

    Date of Birth: (optional)
    For example, 15 3 1984

  • 2. Application to Access Online Medical Records

    This section is to request access to your online medical record

    I wish to have access to the following online services: *YOU CAN SELECT MULTIPLE OPTIONS IF YOU DO NOT REQUIRE FULL ACCESS* (optional)

  • 3. Remove/Restrict Access to Online Medical Records

    This section is to remove/restrict access to your online medical record.

    I wish to have the following online services removed from my access: *YOU CAN SELECT MULTIPLE OPTIONS* (optional)

  • 4. Application to Amend Medical Record Entry Details

    This section is to request a change to an entry within your medical record

    Date of entry in medical record: (optional)
    For example, 15 3 1984

  • Patient declaration

    Date (optional)
    For example, 15 3 1984
    Date (optional)
    For example, 15 3 1984
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Page last reviewed: 09 December 2022
Page created: 01 December 2021