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<b>Health Information Collection and Use, Privacy and Payment Consent Form </b><br><br>

We are committed to protecting the confidentiality of your personal information and health records. In submitting this form, you;<br/>1. acknowledge that we, and our service providers, will collect your personal and health information to enable us to provide you with our health services and any related communications (for example, to manage your appointment bookings); and<br/>2. consent to our handling of your personal information in accordance with our Privacy Policy (you can access our Privacy Policy on our website, or by asking us for a copy).

Please read this consent form carefully, and sign where indicated below. <br><br>

By signing 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:<br>

 – Administrative purposes in running our medical practice. <br>

 – Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.<br>

 – 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.<br>

 – Disclosure to other doctors in the practice for the purpose of patient care .<br>

 – For quality assurance activities to improve our patients health care. <br>

 – To comply with any legislative or regulatory requirements e.g. notifiable diseases. <br>

 – For reminders, which may be sent to you regarding your health care and management.  <br><br>

You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome for you.<br><br>

 – I have read the information above and understand the reasons why my information must be collected. I am aware that our full privacy policy is available on our website urgentcarebrisbane.com.au.<br>

 – I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me<br>

 – I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld. I will be given an explanation in these circumstances.<br>

 – I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.<br>

 – I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice.<br><br>

By signing below I accept responsibility for the fees (including out of pocket fees) related to the services provided which are paid at the time of service which are outlined on our website. 

I understand that if I don’t have a current medicare card that there may be out of pocket fees for pathology or radiology testing from those providers.<br><br>

I accept that I accept these terms and conditions outlined here for any future presentations unless advised in writing. 

For further information please discuss with the receptionist.<br>