Patient Consent Form

Please read this consent form carefully, and agree where indicated below.

As a patient of our medical practice, we require you to provide us with your personal details and full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs.

We aim to protect the privacy and secure storage of your health information. You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information.

We require your consent to collected personal information about you and to use the information you provide in the following ways. Please read this consent form carefully, and agree where indicated below.

Administrative purposes in running our medical practice.
Billing purposes including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your health care including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and the in the reports or results returned to us following referrals.
For research and quality assurance activities to improve individual and community health care and practice management. Usually information that does not identify you is used but should information that will identify you may be required you will be informed and given the opportunity to “opt out” of any involvement.
To comply with any legislative or regulatory requirements – e.g. notifiable diseases.
To contact your or your family for the purpose of recalls and reminders.

You may decline to have your health information used in all or some sort of the ways outlines above but it may influence our ability to manage your health care to provide the best outcome for you.

HEALTH INFORMATION AND USE CONSENT

I have read the information above and understand the reasons why my information must be collected.

I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of health care and treatment given to me.

I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.

I consent to the handling of my information by this practice for the purpose set out above.