<p> ABN 26 875 445 912</p><p>BENDIGO HEALTH CARE GROUP FREEDOM OF INFORMATION APPLICATION</p><p>This form must be accompanied by:</p><p> 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</p><p>FOI requests (if approved) incur the following charges:</p><p> 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</p><p>DETAILS OF APPLICANT</p><p>Surname: …………………………………………………………………..</p><p>Given Name: …………………………………………………………………..</p><p>Address: …………………………………………………………………..</p><p>Postcode: ……………………..</p><p>Telephone No: ……………………..</p><p>DETAILS OF PATIENT/CLIENT</p><p>Surname: …………………………………………………………………..</p><p>Given Name: …………………………………………………………………..</p><p>DOB: …………………………………………………………………..</p><p>Address: ………………………………………………</p><p>Postcode: ……………………..</p><p>Telephone No: ……………………..</p><p>ABN 26 875 445 912 PLEASE INDICATE FROM WHICH CAMPUS(ES) OF BENDIGO HEALTH CARE GROUP YOU REQUIRE INFORMATION</p><p> Bendigo Hospital Campus  Anne Caudle Campus  Psychiatric Services  All of the above</p><p>PLEASE DESCRIBE WHAT INFORMATION YOU REQUIRE</p><p> Full medical record  Other (please specify date range and/or specify parts of the medical record)</p><p>…………………………………………………………………………………..</p><p>…………………………………………………………………………………..</p><p>FORM OF ACCESS</p><p>I request a copy of the documents: YES / NO</p><p>I request to inspect the documents: YES / NO</p><p>DECLARATION</p><p>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.</p><p>Signature: ……………………………………………..</p><p>Date: ……………………………</p><p>Please return your application, $26.50 application fee and a photocopy of your identification to:</p><p>Freedom of Information Officer Bendigo Health Care Group PO Box 126 BENDIGO VIC 3552 Tel: (03) 5454 8307</p>