Branchout Wellness Authority To Release And Transfer Health Records

B. Previous Provider / Record Holder (the ‘Disclosing Provider’)

C. Receiving provider (the ‘Receiving Provider’)

Branch-Out Wellness (Telehealth Clinic – Queensland, Australia)

D. Purpose of disclosure

The purpose of this disclosure is to support: continuity of care; clinical assessment and treatment planning; prescribing governance (including medicinal cannabis); verification of medical history and prior treatments; and compliance with applicable Australian laws and professional standards.

F. Date range / episode of care (optional)

If left blank, this authority applies to all relevant records held by the Disclosing Provider.

G. Method of transfer (tick preferred)

Do not send health information by unencrypted public email or SMS.

H. Fees and copies

Your previous provider may charge an administrative fee to prepare copies of records, as permitted under Australian law. Branch-Out Wellness is not responsible for any fees charged by third parties.

I. Authority and consent

By signing below, I authorise the Disclosing Provider to release the health information described above to Branch-Out Wellness. I understand: (1) the information may include sensitive information; (2) I may withdraw this authority in writing at any time, but withdrawal will not affect disclosures already made; (3) the Disclosing Provider may need to verify my identity before releasing records; and (4) receiving and using these records supports safe care and clinical decision-making.

J. Patient signature

K. Witness (recommended)

L. Clinic use only