Release of Information Form Name * First Name Last Name Subject * Date of Birth * MM DD YYYY NHI If Known Residential Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * Country (###) ### #### Authority to request this information: * I am the client I am the parent / guardian of the child who is under 16 years of age I have written consent from the client I have lawful authority (e.g. power of attorney) over the person’s affairs I have authorisation from the executor of the deceased person’s estate Requestor Name Leave Blank if Same As Above Address of Requester Address 1 Address 2 City State/Province Zip/Postal Code Country Phone of Requester Leave Blank if Same As Above Country (###) ### #### Information requested * Client Appointment Date and Times Client Notes Copy of Referral Copy of Information Submitted via TPG forms Urgent Request? * Yes No Reason for Urgency Delivery Details * Email Mail Collect from Head Office Any other information? We have received your request.We will request you via email for any other documents e.g. ID documents or consent forms.In compliance with the Privacy Act, we will respond to your request no later than 20 working days from date of receipt. If you require your documents before this timeframe, please indicate the date below and the reason for this urgency, We will make every effort to meet a shorter timeframe when requested – but this will not always be possible. We will communicate with you should we be unable to meet your requested timeframe.
