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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
*
Clinic name
*
Clinic address:
*
Type of records requested:
*
Full History
History Summary
Pathology results
Radiology results
To be forwarded via
*
Registered mail
Encrypted email
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
Fax
SMS
Number to send the 2 step verification code to:
Date range
All time
Specific date range
From
+
To
+
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.
First Name
Last Name
Street Address
Address Line 2
City
State
TAS
QLD
WA
VIC
NSW
SA
NT
ACT
NSW
Post Code
Phone Number
Email Address
Date of birth:
+