Authority to request or disclose personal information to external parties

Application/ Tenancy Reference number:

	

Client’s name

General Practitioner Health Professional Support Agency

Date of birth

/	/

Phone Phone Phone

Note:Ticking the ‘Support Agency’ check box does not give the department authority to discuss your case directly with Disability Services. If you wish to give this authority, please tick the Department of Child Safety, Seniors and Disability Services box below.

Department of Treaty, Aboriginal and Torres Strait Islander Partnerships, Communities and the Arts
National Disability Insurance Agency (NDIA)
Department of Child Safety, Seniors and Disability Services

Department of Youth Justice, Employment, Small Business and Training

Services Australia (Centrelink/Department of Veteran Affairs)

Phone:

Queensland Corrective Services Family Members - Names Other:

Queensland Health

Note:Ple:ase note that occasionally it may be necessary to fax this form to one of the individuals/organisations listed  above  to confirm your consent  before  disclosing  or  requesting  information.  If  you  have  any  concerns,  please  discuss  this with your interviewer.

The information will only be requested/disclosed for the purpose of:

Type of information to be requested/disclosed is:

/	/

Date consent commences:

/	/

Date consent ends or former Guardianship and Administration Tribunal or Queensland Civil Administration Tribunal order expires:

or until I remove my consent or I cease to be a client of the Department of Housing. Note: If you have any concerns about signing this form, please contact your nearest Housing Service Centre to discuss the matter.

Name (print)	Signature:

Privacy Notice -  The Department of Housing is collecting your personal information so we may provide you with housing assistance. To assist you with your housing needs and services, your personal information may be disclosed to partner agencies, service providers, local governments and non-governmental agencies that now, or will, provide you with housing and/or support services. Unless authorised or required by law, your personal information  will  not  be  disclosed  to  any  other  third  party  without  your  consent.  More  information  about  the  Department’s  privacy obligations is available on our website at www.housing.qld.gov.au.

Please return completed form to your nearest Housing Service Centre.

Department of Housing
www.housing.qld.gov.au

Page 1 PH071 (27/09/2023)

Authority to request or disclose personal information to external parties	

Sometimes, it may be necessary for the department to contact another person about your housing needs to ensure that we are able to provide the best possible housing outcome for you. There may be a need to have more information about your medical condition or particular equipment within your accommodation.

If this is the case, an officer of the department will explain exactly who the department needs to contact and why. You will be able to nominate a specific person or organisation and the period of time you give consent for the department to receive and pass on your details. You will also be able to specify what we can or cannot talk about with this person or organisation.

The ‘Authority to request or disclose personal information to external parties’ form (PH071), if you sign it, allows the department to contact other people and/or agencies to share information to ensure that the best possible services are available to you.

The Department of Housing is committed to the Queensland Government's Information Privacy Act 2009. The Act describes how personal information is collected, stored, used and disclosed by the Department of Housing.

Unless required by law, your personal information will not be passed onto any other external party without your consent.

Need more information?
Please contact your nearest Housing Service Centre.	

Department of Housing
www.housing.qld.gov.au

Page 2 PH071 (27/09/2023)