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.
Type of records requested: *
Please note that transfrerring medical information via email requires password protection therefore will require a 2 step verification contact. 
Date range *
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Patient information

CLINICAL INFORMATION WILL NOT BE RELEASED TO A 3rd PARTY (eg: Insurance company or employer)  WITHOUT THE PATIENTS SIGNED CONSENT TO RELEASE CLINICAL INFORMATION.
 
 
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