A history transfer fee administration fee of $33.00 is required before a copy of your medical record can be released.
Territory Medical Group - History Transfer Request
This form is to be completed when requesting your history be transferred to a 3rd Party.
Your original history will remain at Territory Medical Group and a copy will be transferred to your nominated medical clinic.
Treating doctors full name
Type of records requested:
To be forwarded via
Email Address to be forwarded to:
Please note that transfrerring medical information via email requires password protection therefore will require a 2 step verification contact.
Send your 2 step verification as
Number to send the 2 step verification code to:
Specific date range
CLINICAL INFORMATION WILL NOT BE RELEASED TO A 3rd PARTY (eg: Insurance company or employer) WITHOUT THE
CONSENT TO RELEASE CLINICAL INFORMATION.
Address Line 2
Date of birth: