Request for Access to Service Records

This form is for people looking to access their health records at PANDA.

The Health Records Act 2001 (Victoria) (the HRA Act) gives individuals a right of access to their personal health information held by any organisation in the private sector in Victoria, in accordance with Health Privacy Principle 6 (HPP6). HPP 6 obliges health service providers and other organisations that hold health information about a person to give them access to their health information on request, subject to certain exceptions and the payment of fees (if any).

Please read our Information Sheet - Accessing Health Records available on our website.

If you need help to understand this form, please contact:

The Quality Officer PANDA

Ph: 1300 726 306

Email: quality@panda.org.au

Please note PANDA is required to verify the ID of all applicants making a request by this form. PANDA will contact you upon submission of this form with instructions on how to verify your ID.

To learn more about your privacy at PANDA, please read our Privacy Policy on our website -

View a factsheet on making a complaint to the Health Complaints Commissioner.

Applicant Details

Surname

Given Name(s)

Date of Birth

Address

Suburb

Postcode

Phone

Email (Applicant)

Are you requesting your own health record or are you making a request as an authorised representative?

Health Record Details

Surname

Given Name(s)

Date of Birth __/__/____

Address

Suburb

Postcode

Phone

Record Request (Authorised Representative)

Applicants wishing to obtain access to a health record other than their own must provide a signed authority from the person concerned. Where the person is deceased, the person’s legal representative must sign the authorisation.

If you do not have a signed authority form, please complete the form below.

Please follow the link to download and complete the entire form.

Please upload the completed and signed form here

Type of Access Required (under the Health Records Act 2001 Victoria):

I wish to receive a summary of my health record (free/ no cost) I wish to obtain a complete digital copy of my health information (at cost*/ record preparation fee up to $149.50 for time to compile record plus postage where required - noting third part redactions may apply. See Appendix A of the 'Information Sheet - Accessing Health Records' for fee schedule)

* People on health care card and/or experiencing financial hardship may apply to have the associated preparation fee reduced/waived.

For more information read our Information Sheet on Accessing Health Records available on the PANDA website.

Contact Information