Referring Doctor

Patient Consent (Health information Collection and Use)

This practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your contact details and a full medical history so that we may properly assess, diagnose, and treat your condition and be proactive in your health care. To enable ongoing care, and in keeping with the Privacy Act 1988 and the Australian Privacy Principles, we wish to provide you with sufficient information on how your personal information may be used or disclosed and record your consent or restrictions to this consent.

Your personal information will only be used for the purpose 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 examples may include: medical test results, notes from consultations, Medicare details, data collected from observations, and details obtained from other health care providers (e.g. specialist correspondence).

By signing the 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 running our practice.

• Billing purposes, including compliance with Medicare requirements.

• Follow-up reminder/recall notices for treatment and preventative healthcare.

• 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 legislation or regulatory requirements e.g. notifiable diseases.

• For use when seeking treatment by other doctors in this practice.

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.

I, ____________________________________ have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purposes other than that set out above, my further consent will be obtained.

I, ____________________________________ give my permission for my personal information to be collected, used and disclosed as described above (including contact via SMS to my mobile number). I understand only my relevant personal information will be provided to allow above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice.

If Patient not signing:

Third Party Authorisation Form

Patient Details

Authorisation

I authorise the person(s) listed below in my nominated Representative/s to:

• Seek and exchange personal information about me and my treatment with Uro Urology Specialist.

• Act on my behalf until this authority is revoked.

I authorise Uro Urology Specialist to seek and exchange personal information about me and my accounts with my nominated Representative’s.

I acknowledge that this Authority will remain in force until revoked. This authority will be revoked when Uro Urology Specialist receive notice from me or my Representative/s to advise authorisation to revoke, or when I appoint a subsequent person to act on my behalf after the date of this authority. 

Representative