Authority to Act, Obtain, Disclose & Discuss Form

Authority To Act, Obtain, Disclose & Discuss Form

Name *

Of,

Address

Address Line 1

Address Line 2

City

State

Zip Code

Born on:

D.O.B.

Associates to:

act on my behalf;
request and receive personal and confidential information and documentation in relation to me;
request and receive report/s from my medical practitioner/psychologist/counsellor for the purpose of acting on my behalf;
disclose personal and confidential information and documentation about me to third parties for the purposes of acting on my behalf;
discuss my legal matter or any other matter relating to me with:

a. my case manager/s and/or support worker/s; and

b. external lawyers for the purpose of referral and any ongoing co-case management following a referral; and

This authority is provided in accordance with the Health Records Act 2001 (Vic).

Name *

First

Last

Signature

Date

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