Medical Records: Application Form and Payment Options

Health Information and Privacy Act 2002 Application Form

Please complete the form and return it to NNSWLHD-LIS-MedicoLegal@health.nsw.gov.au or post to:

Medico-Legal Officer
Clinical Information Services
Northern NSW Local Health District
PO Box 419, LISMORE NSW 2480

Please attend to payment of $33.00 by using one of the options listed.

Payment by Cheque

Cheque written out to Northern NSW Local Health District and post to:

Medico-Legal Officer
Clinical Information Services
Northern NSW Local Health District
PO Box 419, LISMORE NSW 2480

 
Payment by Bank Transfer
Organisation Name Northern NSW Local Health District
ABN 67 284 856 520
Branch Westpac – North Sydney
Account Name Northern NSW Local Health District General Fund
BSB 032-099
Account Number 520749
Swift Code (international payments) WPACAU2S

 
In the reference, please add the name of the person whose records are being requested, along with an identifier for which hospital the payment relates to.

 
Payment in Person

Please present to the relevant hospital reception with your completed form to pay by cash or EFTPOS.

 
Payment by Direct Deposit

Please complete the details on the Payment Form and forward to Northern NSW Local Health District together with your HRIPA Application Form.