Consent 3rd party policy

PATIENT CONSENT FORM

COLLECTION OF PERSONAL INFORMATION, PRIVACY ACT 1988

We require your consent to collect personal information about you. Please read this information carefully, and sign were indicated below.

Kantoko collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, and treat illness and be pro-active in your health care. We will also use the information you provide in the following ways:

• Administrative purposes in running our medical practice.
• Billing purposes, including compliance with Medicare
• 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. If necessary, we will discuss this with you.
• Disclosure to other doctors in the practice, attached to the practice for the purpose of patient care and teaching. Please let us know if you do not want your records accessed for these purposes, and we will note your record accordingly.   

I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information requested of me,but that my failure to do so might compromise the quality of the health care and treatment given to me. 

I am aware that I am free to withdraw my consent at any time by verbal or written notification.

Name of Patient: ……………………………………………………………………………………………

Signature of Patient: ………………………………………………………………………………………… 

Date: ………………….