The Brisbane Eye Clinic respects and upholds
your rights to privacy protection under the National Privacy
Principles contained in the Privacy Act
1998. The National Privacy Principles apply to us from their
introduction
on 21 December 2001. Under these guidelines,
the Brisbane Eye Clinic requires your permission to collect
personal information about you and to use
this information in the management of your medical care. This
practice has a Privacy and Information
Handling Policy and copies are available for your perusal at any time.
Please carefully read the following
information about privacy issues then sign this form where indicated
overleaf. This document will be retained
with your patient records.
The Brisbane Eye Clinic may hold the following information about you:
- Name, address, telephone numbers, email address
- Date of birth
- Occupation
- Health information (including details of
your medical history, family medical history, notes made during
consultations, results of investigations, reports received from other
health providers)
- General practitioner, referring doctor, other specialists involved in your care
- Returned Service Organisation
- Pensioner or Health Care Card details
- Medicare number
- Transaction details associated with services provided to you by providers at Brisbane Eye Clinic
- Additional information provided to us by you
- Information provided to use through patient/referrer surveys
This information is collected in order to provide you with the optimum medical care.
During the management of your medical
condition it may be necessary for the Brisbane Eye Clinic to use this
information in the following ways:
- By providing written or verbal reports
to other Medical Practitioners or allied health professionals involved
in your care to help keep them informed about your progress
- Referrals to other Medical
Practitioners, pathology services, radiology services or allied health
professionals or health organizations for services to assist in your
medical care
- In the event that you are somehow
incapacitated and therefore unable to provide 'informed consent' in
relation to emergency medical care, the person that you nominate as your
next of kin on the 'Patient Information Sheet' will be contacted
- The administration of the medical practice
- To process claims for payment to private
health funds and Medicare in accordance with Health Insurance
Commission and health fund requirements
- To disclose to others for medical defense purposes if necessary
PATIENT'S ACKNOWLEDGEMENT
I have read this form and understand why collecting information about me is necessary.
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. I also understand that
failure to provide this medical practice
with all the information it needs may restrict the practice's ability
to provide quality of health care and
treatment that I require.
I am aware that I have the right to
access the information collected about me except in circumstances
where my access might legitimately be
withheld. I understand that I will be given an explanation in these
circumstances.
I understand that should my information
be required to use for any other purposes other than that set
out above, my consent will be obtained.
I consent to the handling of my
information by this practice for the purposes set out above, subject to
any limitation, access or disclosure
about which I notify this practice in writing now or at any time in the
future.
In addition, I authorise the Brisbane Eye Clinic to contact me via telephone, email, or SMS for
appointment changes and understand that these forms of communication may also be used for
appointment reminders in the future.
I acknowledge that I have read and understand the content within this form.
Should you wish to nominate any restrictions with respect to your personal information, please provide details below: