PATIENT INFORMATION

PERSONAL INFORMATION

PLEASE SPECIFY

SURNAME

FIRST NAME

FULL MIDDLE

GUARDIAN/PARENT(if under 18yr)

DATE OF BIRTH

OCCUPATION

RESIDENTIAL ADDRESS

(If different from above)

Telephone

Home

Work

Mobile

Text Opt in for appointment reminders

YesNo

EMAIL

DO YOU IDENTIFY AS

AboriginalTSI OriginNeither

MEDICAL INFORMATION

MEDICARE No

REF(Number next to Name)

EXPIRY

YOUR GENERAL PRACTITIONER

OTHER SPECIALISTS

PRIVATE HEALTH INSURANCE FUND

MEMBERSHIP NO

LEVEL OF COVER

Emergency

EMERGENCY CONTACT NAME

PHONE

RELATIONSHIP

ACCOUNT HOLDER DETAILS (who is paying for the appointment)

FULL NAME

D.O.B

ADDRESS

MEDICARE NO:

REF

EXPIRY

PLEASE NOTE: This practice does NOT BULK BILL. Payment is required on the day of consultation.

PRIVACY POLICY

PAYMENT IS REQUIRED ON THE DAY OF CONSULTATION.

Services provided: Edge Hill Clinic provides assessment and treatment for children, adolescents and adults who may be experiencing a wide range of emotional or behavioural difficulties. The therapy is provided individually, is time limited and utilises evidence-based interventions. Sessions vary in length depending on the service being offered.

Collection of information: Personal information is collected as part of your/ your child’s assessment and treatment. This information is kept securely on our electronic database, and in the interest of your/ your child’s privacy, is used only by the treating practitioner and the authorised staff of the practice, as necessary. Any information collected is bound by the legal requirements of The Privacy Act 1988.

Confidentiality: With the exception of specific exceptions described below, you/your child have the right to confidentiality. All personal information gathered during the provision of service will remain confidential. However, there are exceptions in which health practitioners are mandated (by law) to break confidentiality. This can occur when:

1. The information is subpoenaed by a court, or disclosure is otherwise required or authorised by law

2. Failure to disclose the information would place your child or another person at serious risk of harm

3. Your prior approval has been obtained e.g. to provide a report to a GP or to contact your child’s school

Cancellation policy: Cancellations made with less than 48 hours notice will incur a fee of $100. Cancellations made on the day of the appointment will result in a fee equivalent to the consult fee. Failing to show up to your appointment without notifying the clinic will result in a fee equivalent to the full consult fee.

Exchange of information: There may be times where, as part of assessment and treatment, it may be helpful for the practitioner to liaise with others involved in you/ your child’s care. Please note that if you intend to claim rebates from Medicare or another organisation, then your treating practitioner must provide summary reports to external agencies. Under the Medicare scheme, these reports are sent to the referring doctor e.g. your child’s GP.

I consent to my information being shared with and collected from the following other services/agencies who are involved in their care, if necessary, as part of their treatment at Edge Hill Clinic:

General Practitioner

YesNo

Psychologist

Yes No

School Counsellor/Teachers

Yes No

Paediatrician

YesMo

Other Allied/ Health Professional

YesNo

Speech Pathologist

YesNo

Occupational Therapist

YesNo

Specific services, agencies or individuals NOT to share information with:

Standard practice is for the doctor to write a brief letter to you or your child’s referring doctor regarding the outcome of treatment.

Are there other medical practitioners you would like correspondence to be sent to apart from your referring doctor and usual GP? If so, please list then:

Name

Address

Phone

CONSENT TO COLLECT PATIENT INFORMATION

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 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:

1. Administrative purposes in running our medical practice.

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

3. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

• 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 some 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.

Patient's/ Legal Guardian's Name

Date

Signature

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