Privacy Opt-Out (Withdrawal) Request

Western Queensland PHN is committed to ensuring that your information is handled in accordance with Australian privacy laws. The PHN uses this form to collect contact details needed to locate the subcription or information collection that you wish to unsubscribe from or opt out of. Your information is never used for commercial purposes. See Privacy Matters for policies and more.

Which information sharing activity you would like to opt out of? *Provide as much detail as you can, how was the information collected- Survey, form, event registration, referral? Which program was this related to e.g. Mental Health, Practice support. Who sent you the request for information?

First Name *

Last Name *

Email Address

I wish to be opted out of sharing my information for the above activity *

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Date *

Template Version:optout230109.01
Template Type: Forrm for completion
Western Queensland PHN
Privacy Officer Approved: 09.01.2023
Controlled Document when Printed