CQRASC Release of Information Form – CQ Respiratory Diagnostics

"*" indicates required fields

Patient Details

Title

Name*

Middle Name

D.O.B*

Mobile Phone*

Home Phone

Work Phone

Address

Address Suburb City State Postcode

Information

Name of Person or Facility*

Address

Facility Address Suburb City State Postcode

Phone*

Fax

The information that may be released subject to this signed release form is as follows:

Pathology Results
Clinic Notes
Radiology Results
Progress Notes
Correspondence
Discharge Summary
Health Summary
Operative Reports
Immunisation Summary
Careplans
Other

By signing this form I authorise the release of my medical records, or a health summary, or narrative of my health information to the requesting clinicians/technicians at CQ Respiratory and Sleep Clinic.

By signing this form I clarify that the above information is true and correct.

Name of Patient or Personal Representative*

Signature of Patient or Personal Representative*

Signature of Requesting Physician*

Date*