Authority to release information form

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Please complete and submit the form below.

This form gives your consent for the TAC to access information about you from other parties related to your transport accident claim. It also allows us to share your information with these parties when necessary. (A list of these parties is on the form below).

If we don't have your consent we may be unable to manage your TAC claim and make decisions about the treatment and benefits we will pay for.

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. Your consent

I consent to the persons and bodies listed below to give relevant information about me to the TAC to help manage my TAC claim:

  • Any doctor, ambulance service, hospital, health service provider*
  • A service provider, e.g. a gardener, cleaner, attendant care worker, builder, etc.
  • An insurer providing Worker’s Compensation insurance or motor vehicle insurance
  • A department, agency or instrumentality of the Commonwealth, the State, or another State that administers taxation, Medicare Australia payments or social welfare laws
  • The National Disability Insurance Agency (NDIA)
  • Law enforcement agencies

The TAC may ask the above for information and documents about:

  • My transport accident injuries, or
  • Any injury or condition that has or may have been affected by the transport accident.

The TAC may also ask about any financial loss suffered as a result of the accident from:

  • My employer (or previous employer)
  • My accountant
  • Financial institutions.

* As defined by the Health Records Act 2001.

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

Are you the TAC client? *
(using a mouse, your finger or a stylus on a touchscreen)
Clear signature
Date
(eg parent/guardian, administrator, power of attorney)
(using a mouse, your finger or a stylus on a touchscreen)
Clear signature
Date
3. Important information

The Transport Accident Act 1986 (the Act), states that when requested to by the TAC, a person must sign this ‘Authority to Release Information 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 may need to share or collect your information from other parties 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 or share relevant information for processing, assessing or managing your TAC claim.

Who may the TAC share your information with?

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.

Other ways the TAC may use and disclose your information

Research

The TAC may use or disclose personal and/or health information for the purposes of research to its research service providers, road safety partners and other government agencies to facilitate research into treatment for, or the prevention of, transport accident injuries.

The TAC removes your identifying information before disclosure so that research can be conducted in either an anonymised form (where your name or identity is not apparent from the data set) or a de-identified form (where your name or identity is not apparent from the data set, and you are not capable of being re-identified).

A list of the TAC’s ongoing research projects for which your information may be used is in the TAC’s Privacy Policy at tac.vic.gov.au

If you wish to opt out of having your de-identified/anonymised information being used or disclosed by TAC for any of its listed research projects, please contact privacy@tac.vic.gov.au

Health Safety and Wellbeing

The TAC is required under the Occupational Health and Safety Act 2004 to provide and maintain a working environment that is safe and without risks to health. Where a client exhibits behaviours of concern (BOC), contracted/ registered service providers to the TAC may be notified for safety purposes. A BOC includes, but is not limited to, where:

  • A threat has been made to any individual’s life, health, safety or wellbeing
  • There is a threat to public health, public safety or public welfare
  • The BOC demonstrated by the Client may pose a risk to the health, safety and wellbeing of a provider(s)
  • There is a risk identified in relation to the environment where the provider(s) would be visiting or treating the client.

The TAC will only share personal or health information that is necessary to advise the provider of the risk in order to protect their health and safety.  Please see the TAC’s Privacy Policy at tac.vic.gov.au/privacy for further details.

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