CONSENT TO COLLECT PATIENT INFORMATION

This medical practice collects information from you for the primary purpose of providing quality health care. We need your personal details and full medical history (which may include photographic records) so that we may properly assess, diagnose, treat and manage your health care needs. This information will be used in the following ways:

1. Adminstrative purposes in running our medical practice

2. Billing purposes - including, but not limited to, compliance with Medicare and the 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

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By submitting this form, you agree that:

• you understand the reasons why your information must be collected

• you understand that you are not obliged to provide any information requested, but that your failure to do so might compromise the quality of the health care and treatment given to you

• you are aware of your right to access the information collected about you, except in some circumstances where access might legitimately be withheld and that an explanation will be given in this circumstance

• you understand that if your information is to be used for any purpose other than the above, we will seek your consent prior

• you consent to the handling of your 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