Release of Health Information | Southern Health | He hauora, he kuru pounamu

1 Current Patient information
2 Health Record
3 Information Requested
4 For official use
5 Child under 16 years of age (legal guardian consent)
6 Consent by patient administration/representative to access information
7 Authorisation to disclose personal information to a third party
8 Complete

This form should be ONLY used if you are a patient or family member requesting information.

All other requests should be directed to the appropriate service.

Date

NHI

Patient full name

Residential address

Date of birth

Contact phone

Email