Access Form for Health Records Held by the Community Services Directorate

Access form for Health Records held by the

Community Services Directorate

(under the Health Records (Privacy and Access) Act 1997, section 12)

PRIVACY NOTICE

This form is to be used for requesting information from the Community Services Directorate under the Health Records (Privacy and Access) Act 1997. The personal information you supply on this form will only be used for the purpose of processing your request. If all or some of this information is not collected, CSD may not be in a position to process your request. Your personal information will not be disclosed to a third party without your consent unless statutory obligations require otherwise.

The CSD Privacy Policy contains information on how you can access or seek to correct any of your personal information that is held by the Directorate, as well as the process for lodging a complaint about an alleged breach of the Information Privacy Act 2014. The Privacy Policy can be found on the CSD website at http://www.communityservices.act.gov.au/home/full_privacy_statement

Details of Applicant

Mr/Mrs/Ms/other

(please use your full name including middle name)

Address:

Telephone: (mobile / home) …………………………….………Work:

Date of birth: Email Address:

I would like to access the following documents located within the following areas of the Community Services Directorate: [Please tick areas you require information from]

☐Housing ACT ☐Multicultural Affairs

☐Child Development Service ☐Office for Women

☐Aboriginal and Torres Strait Islanders Affairs ☐Office for Veterans and Seniors

☐Office for Disability ☐Therapy ACT

☐Family Safety (Coordinator-General) ☐Corporate Services

☐Child and Family Centres (Belconnen, Tuggeranong and Gungahlin)

☐Children, Youth and Families (Care and Protection)

Documents Sought:

I would like access to:

(if insufficient space please attach separate sheet of paper)

I would like:

☐a hard copy of these documents sent to the above address

☐an electronic copy of these documents to the above email

Fees may apply

Please include a copy of your personal identification. The ID can include for example, a driver’s licence, Department Human Services Concession cards, Health Care Card or Medicare Card.

APPLICANTS SIGNATURE

DATE OF REQUEST

Send Request to:

FOI Coordination Team

Community Services Directorate

GPO Box 158

CANBERRA ACT 2601

Enquiries:

Ph: (02) 6205 0244 or (02) 6207 6547

Email:

Further Information

For more information, contact the Community Services Directorate on 133 427.