www.windermere.org.au
Windermere Child & Family Services. Release of Information Form. Client Name: Client File Tracking No:
I consent to the release of information between Windermere and the service and/or practitioner listed below:
Name of Agency and/or Practitioner
Purpose of Request
1. 2. 3. 4. 5. 6.
I DO NOT consent to the release of information between Windermere and the service and/or practitioner listed below: •
•
•
•
Client Signature
Authorised Representative Name (print)
Date
Relationship (e.g. Legal Guardian)
OR
Authorised Representative Signature Date
QUA0004
Release of Information (RoI) – Procedures for Staff Privacy Principle 2, Use and Disclosure, outlines general situations in which personal information can be used and disclosed. In order to comply with Release of Information requirements the following procedures have been developed. These procedures are supported more broadly by Windermere’s Privacy policy. Making A Request for Personal Information Whenever you request personal information from others, it is your responsibility to: • • •
Obtain the consent of the individual whose personal information you are seeking Demonstrate your need to the information holder. NOTE: Doing this allows them to disclose information in their care quickly and with full confidence that the exchange is authorised. Document on file that informed consent has been obtained. NOTE: In order to obtain informed consent a Release of Information form must be completed and stored on file.
Administrative Procedures – completion and distribution of RoI form Where informed consent has been obtained to request personal information from others: 1. 2. 3. 4. 5. 6.
Complete a RoI form listing the services/practitioners you have been given permission to obtain information from. When information is required from three (3) or less external providers, a separate form MUST be completed for each. Where four (4) or more service providers/practitioners are listed on a RoI form, you MUST ensure that all irrelevant information is ‘blocked out’ before distributing the Request for Information externally to the relevant practitioner/ Agency. Block out must be done using white out tape ONLY. You must not disclose Agency names/practitioners or purpose of requests details to services other than the one you are making direct contact with. DO NOT ‘block out’ information on the original copy. Copy the original RoI form and then proceed to block out the irrelevant contacts/practitioners on the copied version. After ‘blocking out’ irrelevant contacts, send the form to the relevant contact. Email distribution is preferable. Document on file that a request for information from an external provider has been lodged.
Responding to a Request for Personal Information In order to promote the efficient and secure sharing of information, it is your responsibility to: • • • •
Verify the identity of the organisation requesting information and the requester’s contact details Verify that your client has given consent for his/her information to be shared. Clarify with the requester why the request is being made If relevant, consider the most secure method of sending the personal information to the requester. NOTE: If emailing do not use the client’s name in the subject box.