FOI-application-form

Application for Access to Documents under the Freedom of Information Act WA 1992 (FOI Act)

Do not use this form for medical record requests for WA health public hospitals.

Please see Healthy WA Website for details

Information type request

Personal information (no application fee or extra charges applicable):
A personal application is a request for records containing your personal information, such as your name, position title, contact details, image or any other identifying matter.

Non-personal information ($30.00 application fee payable upon lodgement of request):
A non-personal application is a request for records concerning matters not only related to you; or containing material related to other people and/or organisations.

Note: Extra charges may also be payable for the processing of documents, as per Schedule 1, Freedom of Information Regulations 1993.

Client details (if applicable)
If you are applying on behalf of another person or are a company representing a business or individual to whom the information you seek relates, please provide their details.

Note: a signed authority from the individual / your client (or business) is required. Organisation / Business details

Authorisation/Attachments

Please attach Letter of Authority (if application) or any other documents and provide details of these attachments.

Details of the specific document(s) being requested: Please provide any dates, reference details, subject matter, document type or any other information to enable the documents to be identified. Your reason for access may also assist with identifying and processing the documents.

Organisation Business Name (if applicable)

Name

Title Mr Ms Mrs Dr etcFirst NameSurname

Australian Postal Address

Street Address

Street Address Line 2

CityState

Post Code

Email

example@example.com

Phone/Mobile

Please enter a valid phone number.

Consent

I consent to all 'personal information' relating to third parties being removed from the requested documents. This includes personal names, position titles, contact details, signatures and any identifying information of third parties. Note: The removal of any (or all) third party 'personal information' will assist with expediting the processing of the documents.

Consent

I consent to my name or my client's name being disclosed to any third party that is consulted on the proposed release of documents as required under sections 32 and 33 of the FOI Act. Note: Providing this information to third parties enhances consultation efficiency as third parties are sometimes more willing to consent to the release of personal and/or business information if the applicant is known.

Detail the specific document(s) being requested: Please provide any dates, reference details, subject matter or any other information. to enable the documents to be identified. Your reason for access may also assist with identifying and processing the documents.

Submission of Request

Email (preferred) : FOI.DOH@health.wa.gov.au Telephone : (08) 9222 6411

Post: FOI Coordinator
Department of Health
PO Box 8172
Perth Business Centre WA 6849