ABN 26 875 445 912
BENDIGO HEALTH CARE GROUP FREEDOM OF INFORMATION APPLICATION
This form must be accompanied by:
A $26.50 (non-refundable) application fee; and a photocopy of a form of identification which has a photograph and signature (eg driver’s licence); supporting documentation if you are applying for another person’s information
FOI requests (if approved) incur the following charges:
search charge of $19.86 per hour or part of an hour rounded to the nearest 10 cents (excludes requests for documents containing information relating to the personal affairs of the applicant) viewing charge of $19.86 per hour, calculated per ¼ hour or part of a ¼ hour rounded to the nearest 10 cents photocopying charge of 20 cents per A4 page
DETAILS OF APPLICANT
Surname: …………………………………………………………………..
Given Name: …………………………………………………………………..
Address: …………………………………………………………………..
Postcode: ……………………..
Telephone No: ……………………..
DETAILS OF PATIENT/CLIENT
Surname: …………………………………………………………………..
Given Name: …………………………………………………………………..
DOB: …………………………………………………………………..
Address: ………………………………………………
Postcode: ……………………..
Telephone No: ……………………..
ABN 26 875 445 912 PLEASE INDICATE FROM WHICH CAMPUS(ES) OF BENDIGO HEALTH CARE GROUP YOU REQUIRE INFORMATION
Bendigo Hospital Campus Anne Caudle Campus Psychiatric Services All of the above
PLEASE DESCRIBE WHAT INFORMATION YOU REQUIRE
Full medical record Other (please specify date range and/or specify parts of the medical record)
…………………………………………………………………………………..
…………………………………………………………………………………..
FORM OF ACCESS
I request a copy of the documents: YES / NO
I request to inspect the documents: YES / NO
DECLARATION
I understand that charges will be made in respect of this request and I will be supplied with a statement of charges which I will pay.
Signature: ……………………………………………..
Date: ……………………………
Please return your application, $26.50 application fee and a photocopy of your identification to:
Freedom of Information Officer Bendigo Health Care Group PO Box 126 BENDIGO VIC 3552 Tel: (03) 5454 8307