Client rep Authority to release information form

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This form allows you to nominate another person to act on your behalf about your TAC claim, and discuss your TAC claim with TAC employees.

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
Date of birth *
Date of accident *
2. Representative’s details
3. Your consent

I give permission for the person(s) nominated in this form to:

  • Act on my behalf about my TAC claim, and
  • Discuss my TAC claim with TAC employees.

This consent includes:

  • receiving all correspondence on my behalf, and
  • making decisions about my TAC claim, such as requesting treatment and services, and
  • requesting personal and health information about me, and
  • changing my personal details, including my contact details and bank account details.
(using a mouse, your finger or a stylus on a touchscreen)
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Date
Important information

Your privacy

The TAC will retain the information provided and may use or disclose it to make further inquiries or assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information.
If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our website at tac.vic.gov.au