Patient Portal - Proxy Access Request

Please complete the form below to request access to the medical record of a patient in your care. For patients 16 years and older, proxy access must be requested in person at the patient's primary Health Service or by completing a printed copy of the Health Hub Sign-up Form.

Step 1 | Patient Details:

Parent/legal guardian, please fill in the details for the patient in your care:

Health Service:

Please select the primary Health Service the patient attends. This information will be used to send the request to the correct location for processing.

First name:

Last name:

Date of Birth:

Patient UR number (if known):

Street address:

Suburb/Town:

State:

Post Code:

Phone:

Step 2 | Proxy Details:

Parent/legal guardian, please fill in your details:

First name:

Last name:

Date of Birth:

Relationship to patient:

Your UR Number (if known):

If you're also a patient at The Royal Melbourne Hospital, The Women's or Peter MacCallum Cancer Centre, we can create a single account to view your own medical information and also the information for the patient in your care.

Street address:

Suburb/Town:

State:

Postcode:

Phone:

Email:

Step 3 | Identity Verification:

To keep our patient's medical records protected and secure, a copy of your photo identification (which displays your full name and date of birth) is required to verify your identity. Proof of identification must be provided by email by choosing the relevant Health Service link below. The photo ID will be used solely to verify identity and will not be permanently stored.

The Royal Melbourne Hospital

The Royal Women's Hospital

Peter MacCallum Cancer Centre

Were you able to successfully send proof of identification as described above?

Yes

ID Reference number:

Please supply the reference number found on your ID - e.g. Driver's licence, passport, proof of age card etc.

Important: Your account access request will not be reviewed or approved until a valid form of photo identification has been recieved (e.g. driver's licence, passport, proof of age card).

Step 4 | Please read and sign this form:

You must read, understand, and agree to the Terms and Conditions of Use posted on the Health Hub website before an account can be provided. Once you have read this document and agree to the terms, please sign the form below:

Click the statement to the right to sign this form electronically - it will turn blue when clicked.

By signing this form electronically, I certify that I am the parent or legal guardian of the patient identified above, and the information I have provided is correct. I acknowledge that I have read, understood and agree to abide by the Health Hub Terms and Conditions of Use linked above.

Based on the information you provided, we will post, email or text you the details to sign up for Health Hub. Please allow seven business days for these requests to be processed. Should we have any questions regarding your submission, we will contact you via the telephone number or email you have submitted.

Proxy Access Request for Patient 0-15 years

Step 1 | Patient Details:

Step 2 | Proxy Details:

Step 3 | Identity Verification:

Step 4 | Please read and sign this form: