Unit 75, Level 4, Wexford Medical Centre
3 Barry Marshall Parade, Murdoch, WA 6150
Phone : (08) 6389 0631 | Fax : (08) 6313 0613
info@coastalgastro.com.au

Patient Information & Privacy Form

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1
First Name
Surname
DOB

Home / Postal Address

Street Addressyour full name
Suburb
Postcode
Phone No.
H:
W:
M:your full name
Medicare
Medicare numberMedicare number
RefRef
Private Health Fund
Fund Name
Membership No.
DVA
DVA
Card
Expiry Dateof appointment

( Dept. Veteran’s Affairs )

HCC/Pension Card
Card Number
Expiry Date
Next of Kin
Contact No
Referring Doctor
Doctor Name
Contact No

CONSENT TO COLLECT PATIENT INFORMATION

This medical practice collects information from you for the primary purpose of providing ongoing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:
  • Administrative purposes for running of our medical practice.
  • Billing purposes, including compliance with Medicare and the Health Insurance Commission requirements.
  • Disclosure to others involved in your health care, including treating healthcare professionals, specialist doctors and diagnostic providers outside this medical practice, as advised by you, to ensure delivery of ongoing quality healthcare to you.
  • I consent to the release of my previous pathology, radiology and other medical test data to my treating physician for the purpose of providing care to me.
  • I understand the reasons why my information must be collected.
  • 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 rare circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
  • I understand that if my information is to be used for any purpose other than the above, my consent will be sought.
  • 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 of which I may notify this practice.
  • I consent to this medical practice communicating with me electronically for convenience and environmental reasons, and I understand email and SMS are not consider secure under WA Department of Health standards.

By typing your name below and answering the personal security question you are electronically signing this form and consent to the terms specified above
Answer
Printed Name
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