Sketch the area of interest on the diagram.
Red = very painful, Green = moderately painful, Blue = pain but negligible.
Please sign within the box.
The provision of quality health care requires a practitioner-patient relationship of trust and confidentiality. Consistent with our commitment to quality care, Flex Health Professionals has developed a policy to protect patient privacy in compliance with current legislation.
This means we will collect information that is necessary to properly treat you. Such necessary information may include;
• Full medical history, family medical history, contact details
• Ethnicity, genetic information
• Medicare/private health fund details and billing/account details
The information will normally be collected directly from you. There may be an occasion when we will need to obtain information from other sources;
• Other medical practitioners, e.g GP’s and specialists
• Other health care providers such as physiotherapists, occupational therapists, psychologists, pharmacists, dentists, nurses, hospital and day surgery units.
Both our practice staff and health practitioners may participate in the collection of this information. In emergency situations we may need to collect personal information from relatives or other sources where we are unable to obtain your prior consent.
USE & DISCLOSURE:
With your consent, the practice staff will use and disclose your information for purposes such as:
• Account keeping and billing purposes for the management of our practice
• Referral to another medical practitioner or health care provider
• Referral for further tests e.g x-rays
• Referral to a hospital for treatment options
• Quality assurance, practice accreditation and complaint handling
• To meet our obligations of notification to our medical defence organizations or insurers
• To prevent or lessen a serious threat to an individual’s life, health or safety
• Where legally required to do so, such as producing records to court, mandatory reporting of child abuse or the notification of diagnosis of certain communicable diseases.
You are entitled to access your own health record at any time convenient to both yourself and the practice. Access can be denied where:
• To provide access would create a serious threat to life or health
• There is a legal impediment to access or if your request is frivolous
• The information relates to anticipated or actual legal proceedings and you would not be entitled to access the information in those proceedings; and
• In the interest of national security
We ask that, where possible, your request be in writing. We may impose a charge for photocopying or for staff time involved in processing your request. Where you dispute the accuracy of the information we have recorded, you are entitled to correct the information. It is our practice policy that we will take all steps to record all of your corrections, and place them with your file but will not erase the original record.
I provide my consent for the staff and practitioners at Flex Health Professionals to collect, use and disclose my personal information as outlined above.
I understand that I am entitled to access my own health records except where access would be denied as outlined above.
I understand that I may withdraw my consent as to use and disclosure of my personal information (except when legal obligations must be met).