New Patient Information Form

Health Information Collection and Use Consent Form

Please read this consent form carefully, and sign where indicated below

• Payment is required at the end of the consult and we accept credit card, eftpos and cash. (No cheques, Diners or Amex)
• Medicare will rebate you a portion of the fee. We can lodge this here only if you have provided Medicare with your bank details.
• PLEASE NOTE: There may be extra costs additional to your consultation ie: Urine and Blood testing, Suturing etc. Pathology and radiology costs are not generated from or associated with our practice.
• IMPORTANT: GP After Hours Mount Lawley DOES NOT PRESCRIBE SCHEDULE 8 DRUGS Your personal information will only be used for the purposes for which it was collected or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed.

The information we collect may be collected by a number of different methods, and may include, but not limited to: medical test results, notes from consultations, Medicare details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g. specialist correspondence). By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by the practice for the following purposes:

• Administrative purposes in the operation of our general practice.
• Billing purposes, including compliance with Medicare requirements.
• Follow-up reminder/recall notices for treatment and preventative healthcare, frequently issued by SMS.
• 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 in the reports or results returned to us following the referrals.
• Accreditation and quality assurance activities to improve individual and community health care and practice management.
• For legal related disclosure as required by a court of law.
• For the purposes of research only where de-identified information is used.
• To allow medical students and staff to participate in medical training/teaching using only de-identified information.
• To comply with any legislative or regulatory requirements, e.g. notifiable diseases.
• For use when seeking treatment by other doctors in this practice.

At all times we are required to ensure your details are treated with the utmost confidentiality. Your records are very important and we will take all steps necessary to ensure they remain confidential. Please complete the form below if you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information.