Authority to release - Medical practitioner - TAC

This form gives us permission to collect information about you from a medical practitioner to help us make the payments for the treatment and services you need. It also enables us to disclose information to other parties so we can manage your claim.

We will also never ask you to disclose passwords or transfers fund into an unknown bank account. Please contact us if you have any concerns.

We treat your personal information in confidence and in line with the TAC privacy policy.

1. Personal details

First Name *

Last name *

TAC claim number *

Address *

Suburb *

Postcode *

Date of birth (dd/mm/yyyy) * Day Month Year Day Month Year

Date of accident (dd/mm/yyyy) * Day Month Year Day Month Year

2. Practitioner's details

Practitioner's first name *

Practitioner's last name *

Practitioner's phone number *

Practitioner's address *

Practitioner's suburb *

Practitioner's postcode *

3. Authorisation Authorising persons name I ,

authorise you to provide the TAC with information and documents relevant to:

My transport accident injuries
Any injury or condition that has or may have been affected by the transport accident
A summary of the treatment I have received to date
The results of any x-rays
Copies of my medical records
Your opinion in relation to:
1. the treatment that I still require and its expected duration
2. whether I am able to carry out my normal employment (in full or in part) or any alternative employment
3. the expected period of further incapacity

The TAC will only collect information pertaining to the injuries and time periods relevant to the administration of my TAC claim.

Please sign in the box below (using a mouse, your finger or a stylus on a touchscreen)

Clear signature

Name *

Date (dd/mm/yyyy) Day Month Year Day Month Year

Important information

Information about this consent form
This is an ‘Authority to Release Information: Medical Practitioner’ form. The Transport Accident Act 1986 (the Act), states that when requested to by the TAC, a person must sign this form. Section 67 of the Act also says that this form cannot be revoked until a claim is finally determined.

Why does the TAC need this information?
The TAC needs your information in order to carry out its functions under section 12 of the Transport Accident Act 1986.
These functions include assessing claims for compensation, defending proceedings, paying compensation, etc.
The TAC will only use this form to collect relevant information for processing, assessing or managing your TAC claim.

What happens if you don’t sign this consent form?
If you do not sign this consent form, the TAC may not be able to make decisions about your entitlement to TAC benefits.

Who will the TAC disclose your information to?
The TAC may disclose the personal and health information it has obtained about you where it is required by law to do so, or where it is necessary to manage your claim for compensation.
It may be necessary to disclose your information to:

Medical and health service providers
People providing a service to you, such as a gardener, cleaner, attendant care worker, builder, etc.
A person that is contracted to provide services to the TAC, relevant to the management of my TAC claim
Your employer
A solicitor acting in relation to your TAC claim
Other government agencies, such as the Victorian WorkCover Authority or the NDIA
A court or tribunal
A person you authorise to obtain the information.

Getting access to your information
You can get a copy of this form or information we have collected about you by contacting the TAC.

More information

If you require further information about the TAC’s privacy policy, or if you have any questions about how we collect or share your information, please call us on 1300 654 329 or visit our website at tac.vic.gov.au