Patient Referral Form

PRIVACY ACT 1988
PATIENT CONSENT TO COLLECT & DISCLOSE INFORMATION
We require your consent to collect, use and disclose personal information about you. Please read this information carefully and sign
where indicated below.
This medical practice collects information from you for the primary purpose of providing quality health care to properly advise and
treat you. Such information may include:
• Full medical history
• Family medical history
• Ethnicity
• Personal contact and health fund details
• Genetic information
Both our practice staff and medical practitioners may participate in the collection of this information.
This information will normally be collected directly from you. There may be occasions when we will need to obtain information from
other sources such as other doctors, other health providers or hospital.
With your consent, we may use the information you provide us with, in the following ways:
• Administrative purposes in running our medical practice
• Account keeping and billing purposes
• Disclosure to others involved in your health are, including treating doctors and specialists outside this medical practice,
including other health care providers and insurance/health fund companies. This may occur through referral to other doctors
or for medical tests and in the reports or results returned to us following such referrals.
• Disclosure for research and quality assurance activities to improve individual and community health care practice
management. You will be informed when such activities are being conducted and given the opportunity to “opt out” of any
involvement.
• Where legally required, such as providing records to court, mandatory reporting or child abuse or the notification of certain
communicable diseases.
You are entitled to access your own health records at any time convenient to both yourself and the practice except in some
circumstances where access might legitimately be withheld or where your request is frivolous. A charge may be imposed for
processing your request. Where you disagree with the accuracy of the information recorded please discuss this with your doctor as
you are entitled to have your corrections included in your file.

I have read the information above and I provide my consent for Dr Snigdha Saha and associated practice staff to collect, use and disclose my personal information as outlined above.
I understand that I am not obliged to provide any information requested of me, but that my failure to do so, may compromise the quality of the health care and treatment given to me.
I understand that I am entitled to access my own health care records except where access might be legitimately withheld. I understand that I will be given an explanation in these circumstances.
I understand that I may withdraw my consent to the use and disclosure of my personal information (except where legal obligations must be met).