PATIENT REGISTRATION FORM

Tel: 03 7001 3535
Fax: 03 9960 6161
Email: info@drmeei.com.au
www.meeiyeung.com

PATIENT DETAILS

dd/mm/yyyy


SECONDARY CONTACT DETAILS

DOCTOR'S DETAILS

If same as GP, please leave leave "As above"

MEDICARE

Number preceding name on card
mm/yyyy

PRIVATE HEALTH INSURANCE


(mm/yyyy)

PRIVACY CONSENT FORM

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


Collection

This medical practice 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, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:

  • Administrative purposes in running our medical practice including telephone confirmation of appointments

  • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements

  • 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.

  • Disclosure to other doctors in the practice, locums and by Registrars attached to the practice for the purpose of

  • patient care, teaching and research.


Use and Disclosure

We will treat your personal information as strictly private and confidential. We will only use or disclose it for purposes directly related to your care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment. For example, the disclosure of blood test  or biopsy results to your GP.

There are circumstances where we may be permitted or required by law to disclose your personal information to third parties. For example, to Medicare, Police, insurers, solicitors, government regulatory bodies, tribunals, courts of law, hospitals, debt collection agents, the electronic transfer of prescriptions service or to the Myhealth record system. We may also from time to time provide statistical data to third parties for research purposes.

We may disclose information about you to outside contractors to carry out activities on our behalf such as an IT service provider, solicitor or debt collection agent. Outside contractors are required not to use information about you for any purpose except for those activities we have asked them to perform.


We may also need to contact your General Practitioner and/or Specialists you have consulted, to request additional medical information from them.


Please let us know if you do not want your records accessed for these purposes and we will note your record  accordingly.


Data Quality and Security

We will take reasonable steps to ensure that your personal information is accurate, compete, up to date and relevant. For this purpose our staff may ask you to confirm that your contact details are correct when you attend a consultation. We request that you let us know if any of the information we hold about you is incorrect or out of date.

Personal information that we hold is protected by:

  • securing our premises;

  • placing passwords and varying access levels on databases to limit access and protect electronic information from unauthorised interference, access, modification and disclosure.

Access

You are entitled to request access to your medical records. We request that you put your request in writing and we will respond to it within a reasonable time.

There may be a fee for the administrative costs of retrieving and providing you with copies of your medical records.

We may deny access to your medical records in certain circumstances permitted by law, for example, if disclosure may cause a serious threat to your health or safety. We will always tell you why access is denied and the options you have to respond to our decision.

  • 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 of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

  • I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.

  • 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.

  • I consent to the use of my non-identifying clinical photographs and videos for educational purposes in the practice/at medical lectures or medical journals.

SIGNATURE

Draw signature|Type signatureClear