The law gives you certain privacy rights in relation to information that you give to this medical practice. We need your consent to collect personal information about you. The fact that you have come here implies that you consent to us knowing about your health situation either for a particular event or generally. This form provides a summary of your rights in relation to the use of the information and, how we may disclose it to other medical service providers.
The information we ask you to give us is deeply personal. However, not having it will restrict our capacity to provide you with the standard of medical care that you expect.
Please carefully read the following information about privacy issues and then sign this form. It will go on your file, and you may examine it or change it at any time.
We collect health information from you mainly to assess, diagnose, and treat your condition properly and to be proactive in your health care. Health information is anything we collect about you in relation to providing healthcare to you. This may include verbal, written, or visual (e.g. images or videos) information. We will also use the information you provide in the following ways:
Administration of this medical practice
Billing, including compliance with Medicare and legislative requirements
Disclosure to others involved in your care, including doctors and specialists outside this practice who may become involved in treating you. This may occur through referral to other doctors, or for medical tests and, in the reports returned to us following the referrals. If necessary, we will discuss this with you;
Disclosure to other doctors in the practice and locums if required.
PATIENT ACKNOWLEDGEMENT
I have read this form and understand why collecting information about me is necessary. I am also aware that this practice has a privacy policy for managing patient information.
I understand that I am not obliged to provide any information requested of me. I also understand that failure to provide this medical practice with all the information it needs may restrict the ability to provide the quality of health care and treatment that I require.
I am aware that I have the 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 purpose other than that set out above, my permission, in writing, will be sought before any action is taken.
I authorise Northern Beaches Pain Management to communicate with me using details provided on this form.
I acknowledge that I have read this form before signing it and, that a member of staff of this practice has, at my request, clarified any aspects of it that I did not at first understand.
CONSENT FOR RELEASE OR ACQUISITION OF MEDICAL INFORMATION/RECORDS
I give my permission for Northern Beaches Pain Management, its healthcare professionals, contractors, and employees to either release or request any medical information/records relevant to me as required.