patient details form

CONSENT TO COLLECT PATIENT INFORMATION / AUTHORISATION TO RELEASE RELEVANT MEDICAL INFORMATION TO A THIRD PARTY

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:

1. Administrative purposes in running our medical practice
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
3. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you

I understand the reasons why my information must be collected.

I understand that I am not obliged to provide any information requested of me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.