Patient Information and Consent Form

By signing below, you (as a patient/guardian) are consenting, that on obtaining your personal health information it may be used or disclosed by the practice for the following purposes:

• Follow up reminder/recall notices for treatment and preventive healthcare, and appointment reminders to phone numbers provided by you.
• For use when seeking treatment by other doctors in this practice, as this is a group practice using shared electronic records.
• The diagnosis and treatment of any health condition, including the communication of relevant information only, to practice staff, specialists and other healthcare providers to ensure quality care is provided.
• Acquiring relevant tests (blood tests, radiology) from other practices for patient treatment.
• For practice accounting procedures and the collection of professional fees, both internally and via debt collection services.
Accreditation and Quality Assurance activities are conducted by professionally trained non-treating GP’s or others e.g. Nurses and Practice Managers.
• For legal related disclosure as required by a court of law, child protection agencies or in response to a subpoena or disease notification required by law
• For third party requests by organisations such as insurance companies and lawyers. Such disclosure is only made when you provide an authorisation to the insurance company or lawyer for us to release information which often includes information that is not directly related to your claim. A fee will be charged to you for this service.
• When you have a claim under workers compensation, it is a legal requirement that any treating doctor who writes WorkCover medical certificates for you must provide information when requested, to the Workers Compensation Organisation.
• 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.
• Where you are unable to act on your own behalf due to a health condition, we may need to discuss your health information with relatives or emergency contacts, in order that you are provided with appropriate care.
• We will not send your medical information to anyone overseas, unless you specifically consent for us to do so, or it is a requirement by law.
• By signing below, I understand that Perth Surgical Clinic is a private billing practice and agree that any residual fees are my financial responsibility, payable at the time of consultation or prior to my procedure.

I give permission for my personal health information to be collected, used and disclosed as described above. I understand only my relevant personal health information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.