In accordance with section 6(1) of the Privacy Act 1988 (Cth) (“Privacy Act”), all information collected in this practice is treated as ‘sensitive information’. To protect your privacy, {INSERT PRACTICE ENTITY AND ACN} (“Newcastle Health Solutions”) operates in accordance with the Privacy Act and its Privacy Policy. A copy of our Privacy Policy is available free of charge from reception or on our website.
This policy provides guidelines on the collection, use, disclosure and security of your information. It also contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy.
Your practitioner needs to collect your personal information, employment history and full medical history for the primary purpose of assessing, diagnosing, treating and being proactive in your health care, which may include using the information for the following purposes (including instructing Newcastle Health Solutions to use the information for the following purposes on your practitioner’s behalf):
a. Using your personal and health information to undertake, however not limited to, administrative tasks involved in the running of Newcastle Health Solutions, and for your practitioner, billing tasks which includes compliance with Medicare, Health Insurance Commission and other relevant Government agency and insurance requirements.
b. Collecting, recording and storing your personal and health information that will form part of an individual computerised record.
c. In the case of an insurance or compensation claim it may be necessary to disclose and/or collect information that concerns your return to work to an employer/potential employer, insurer or other third party.
d. In the case of a pre-employment medical, rail medical or other occupational assessment, it may be necessary to disclose and/or collect information that concerns your suitability to work in a particular role to an employer/potential employer, insurer or other third party.
e. Contacting you regarding results, upcoming appointments or health checks that you may require, if any, as part of your consultation with your practitioner and/or nurse.
f. Providing you with health information updates, general medical updates and provide your personal and health information to the relevant state and/or national recall reminder registers.
g. Billing either directly, to your employer/potential employer or through an insurer or compensation agency;
You can assist in maintaining the accuracy of your information by advising your practitioner or reception of changes in your contact details.
You hereby acknowledge and consent to the disclosure and/or use of your personal health information by Newcastle Health Solutions, your practitioner and persons directly or indirectly involved in the assessment of your health for that purpose, including:
a. Disclosing your personal, health information, assessment results and progress to the relevant services providers including, but not limited to medical and allied health services providers involved in your care, insurers or employers.
b. Using your personal and health information by your practitioner and other authorised individuals involved in your medical care and treatment, both directly and indirectly.
c. Disclosing for legal related purposes as requested and required by a court or other regulatory body.
d. For medical training/teaching purposes where de-identified information is disclosed to medical students and staff.
e. For medical letters and or reports which will be sent directly to the referrer.
f. For disease notification as required by the law.
Unless stated otherwise, you understand your practitioner requires payment on the day for services they provide. Failure to make payment on the day and before close of business will incur an additional administration fee as set by your practitioner for the time and resources taken to recover full payment.
If you have any questions or concerns about any of the information on this form, you will request to speak to the Practice Manager or notify the Practice Manager in writing.
I, , have read the above information and:
*Unless stated otherwise -consent is deemed valid for 12 • months, for Occupational Health and Workers Compensation matters.
If you have any questions regarding the management of your personal health information or need to arrange to access to your records, please ask reception or your doctor, as appropriate.
Please sign this form as confirmation that you have read, understood the appointment and fee information and consent to the use of your personal and health information as stated above.
If you do not wish for this to occur, please advise reception or your practitioner.
Signature:
Name:
Date of Birth:
Parent/Guardian Signature: ________________________
Parent/Guardian Name: __________________________
Date signed: _______________
{INSERT PRACTICE ENTITY AND ACN} (“Newcastle Health Solutions”) collects your personal information for purposes related to (or in the case of sensitive information, directly related to) our functions or activities, including facilitating the accurate assessment, diagnosis and treatment of your health from your practitioner, informing you of services which may be relevant to you and to communicate with you on behalf of your practitioner. We may not be able to facilitate the above if you do not provide this information. Your personal information may be disclosed to our related bodies corporate, your practitioner, employer/potential employer, insurer or third-party services providers as required. Your personal information is kept private and secure, as required by federal and state privacy laws.
Please refer to our Privacy Policy for full details of how we handle your personal information, including how you may access and seek correction of your personal information, complain about a privacy breach, and how we will deal with that complaint.
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