Health Practice Closure, Merger or Relocation Online Form

You are required by the Health Records (Privacy and Access) Act 1997 to publicly advertise the closure, merger or relocation of your practice in a transfer notice 30 days prior to the closure, merger or relocation.

You are also required to notify ACT Health of the transfer notice information as soon as practicable after publication (please see the form below). ACT Health is required to forward this information to the ACT Health Services Commissioner.

If you are closing, merging or relocating a health practice, please complete this form.

In this section:

Health Practice Closure, Merger or Relocation

1. Is the practice:

	Closing
	Merging
	Relocating

2. If closing, merging or relocating a health practice, have you placed a public transfer notice of the closure, merger or relocation of the practice in the local newspaper?

	Yes
	No

If no, please place a public transfer notice in the local newspaper before completing this form.

If yes, where has the public transfer notice been placed?

Date of public transfer notice?

3. Name of Current Practice

Address

Phone Number

Fax Number

Email Address

4. Where will health records be held?

	relocated practice (go to Question 5)
	other please specify

Name of location of health records

Address

Name of record keeper

Address

Phone Number

Fax Number

Email Address

5. Name of Merged or Relocating Practice

Address

Phone Number

Fax Number

Email Address

6. When will health records be moved?

7. Your name and designation in the practice?

8. Name of Contact Officer for Queries and Complaints

Address

Phone number

Fax number

Email Address

You have now completed the form. Please select the Submit button below. An automated copy of your form will be forwarded to the Health Services Commissioner.

ACT Government Health Directorate Australian Capital Territory Health Information

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Health Practice Closure, Merger or Relocation Online Form

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