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Copies of Examinations

Request copies of specific examinations for a new Health Care Provider

Once your final results are returned to your requesting health care provider, you may make a non-medically urgent request for copies of examinations be made available electronically to:

  • A new practitioner such as an out of area specialist
  • Yourself if, for eg, you are moving interstate OR did not receive a set of images during your original examination. NOTE: Conditions apply and copies may incur a fee.

Patient request copy of examination(s)

You can request a specific examination or all examinations. If you request films, they will have to be picked up and might incur a cost.

Specific Examination/Study Information

Indicate the specific examination or most recent examination if requesting more than one

Patient Information

(first name and surname)
(inc area code)

Practitioner information

(We will need to contact this practitioner directly)
(eg Dr John Smith)
(Note that copies may incur a fee). Requests for physical film will require the patient to collect directly from patient's local branch

Consent and Sign off

I acknowledge and agree that:
1. I understand that I will not be permitted to remove the contents of my medical record from the premises of the North Coast Radiology Group premises, nor will I be permitted to alter or erase information contained in the medical record.
2. I will be permitted to obtain copies of some or all of the contents of my medical record. Where copies are requested, a fee may be applicable. Further, I understand that copies may not be available at the time of inspection of my medical record, and will be made available to me as soon as practicable following the inspection.
I acknowledge and agree that:
Where this request is for copies not previously supplied at the time of my original appointment, an administrative fee of $22.00 will apply to my request. Further, provision of copies of printed pages will be at the cost of $2.50 per page, and provision of images will be at the cost of $22.00 per film and/or $22.00 per disc. These costs are inclusive of GST. If I have a condition that is suitable for inclusion in a clinical trial I consent to being contacted by the clinical trial coordinator about possible inclusion, and I understand that I can decline any such offer of inclusion at any time.

Where the request relates to requesting radiology examination images and or reports be made available to a new provider eg a specialist who is not local I am consenting to North Coast Radiology Group transfering the result/s of my examinations electronically to that new provider per the details provided within this form or subsequently over the phone.

Please use your mouse to sign this form

On receipt of your request we will contact you and any new providers to validate and facilitate the transfer of information.