UHG specific authority

Please complete and submit the form below.

This form gives your consent for the TAC's third-party provider, Unified Healthcare Group (UHG), to contact other parties and access medical information about you that is related to your transport accident claim.

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.

First name *

Last name *

Maiden name (if relevant)

Date of birth *

TAC claim number *

I authorise the disclosure of any medical and personal information held by any third party, including any medical practitioner, health professional, hospital, clinic or other health service professional, whether named by me or not, to Unified Healthcare Group or an agent acting on behalf of your insurance company, for the purposes of assessing an insurance application or claim.

I understand that my file contains sensitive information, and I authorise the release of this sensitive information.

Signature *

Clear

(using a mouse, your finger or a stylus on a touchscreen)

Date signed

Your privacy

The TAC respects your privacy. The TAC will retain this information 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 compensation. We will disclose this form to UHG, for the purpose of collecting information about you on the TAC’s behalf. 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 privacy policy.