Multi-Agency Medical Record Release and Consent to Share

I authorise information to be handled only for the purposes I select below.

No information may be used or disclosed under this consent for an unrelated purpose.

I authorise the following selected actions.

My selection does not authorise access to information outside the categories, recipients, purposes and period stated in this form.

I authorise information exchange only with the organisations and people individually selected or identified below.

Custodial and prison health services

Health departments and monitored-medicines bodies

Community justice and reintegration services

Selection of an organisation in this section does not authorise disclosure of clinical information unless the relevant information category is also selected in Part 5.

Nominated community pharmacy

Nominated general practitioner

Other health practitioner, support person or specialist

I authorise only the categories I select below.

Opioid dependence treatment and medication safety — only if applicable

Leave this section blank if the patient is not receiving or seeking ODT/OST.

General clinical information

Pathology and diagnostic information

Mental-health information

Complete counselling notes may contain information about other people. They will only be disclosed where lawful, reasonably necessary and appropriate.

Justice and scheduling information

I understand this category is separate from my clinical information.

Justice and support organisations may receive clinical information only where I have selected that organisation in Part 4, selected the relevant clinical category in this Part, and the disclosure is reasonably necessary for a selected purpose.

Additional limitations

By signing this form, I confirm that:

1. I have read this form, or it has been read and explained to me;
2. I understand the organisations, purposes, information categories and directions I selected;
3. I understand that I may decline, limit, change or withdraw my consent;
4. I have had an opportunity to ask questions and received answers I understand;
5. I give my consent voluntarily and have not been pressured to sign;
6. CMYNP PTY LTD will use reasonable steps to limit information exchange to what is reasonably necessary for the purposes I selected;
7. I understand that exchanging accurate dosing and medication information may assist medication safety and continuity of care following release; and
8. the information I have provided in this form is accurate to the best of my knowledge.

Interpreter

Support person

Substitute decision-maker

This Part concerns appointment scheduling only. It does not authorise the representative to make clinical decisions, access clinical records or receive clinical information unless separately authorised elsewhere in this form.

A telehealth link should ordinarily be sent directly to the patient where the patient can safely receive it.

This permission ends when the initial appointment is completed, cancelled without rebooking, or when I withdraw the permission, whichever occurs first.

This Part is to be completed where the patient signs in custody and a correctional case manager, parole officer, transition coordinator, health worker or community support worker witnesses the signature.

I confirm that:

1. I verified the patient's identity against official Corrective Services records or their Gaol Photo Identification while they were in custody (NSW Health Positive Identity / Custodial Witness Protocol);
2. I witnessed the patient sign this form or witnessed the patient's substitute decision-maker sign it;
3. to the best of my knowledge, the patient or substitute decision-maker appeared to understand the nature and effect of this consent;
4. the patient had an opportunity to ask questions; and
5. I did not pressure or improperly influence the patient to sign.

I do not certify the patient's legal or clinical decision-making capacity unless I am appropriately qualified and authorised to make that assessment.

Why this matters: telehealth guidelines (NMBA / Medical Board) and RACGP Criterion CG2 require identity to be verified before prescribing. Many people leave custody without a licence, passport or Medicare card, so this custodial witness declaration is accepted instead. CmyNP records in Halaxy that identity was verified by custodial witnessing — no copies of ID are stored.