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Managing Pain Clinic | Patient information form
Patient Personal Information and Consent - CONFIDENTIAL
Title
Dr
Mr
Mrs
Ms
Miss
Family name
Given name
Preferred name
DOB
Address
Home phone
Mobile
Work phone
Email
Next of kin
Relationship
Contact number
General Practitioner
Practice Name and contact number:
Specialist
Practice Name and contact number
Other interested parties you would like copied in on our letters
Have you had any scans related to your condition?
yes
no
Location
South Coast Radiology
Advanced Radiology
North Coast Radiology
QScan
QLD X-ray
Type
X-ray
Ultrasound
CT Scan
MRI
Nerve conduction Study
Area interventions such as Steroid Injections
Medicare Number
Reference on Card
Expiry date
Private health fund
Membership Number
Have you been a member of your health fund for over 12 months?
yes
no
DVA Card
white
gold
Card number
Have you received prior approval for your appointment from DVA?
yes
no
WORKCOVER AND CTP PATIENTS
Name workcover agency/ Insurance company
Claim ID reference no
Case Manager Name
Email
Contact number
CONSENT (The Managing Pain Privacy policy is detailed below. Your signature acknowledges you have read and understand our policy)
I consent to the collection of my personal health information, including information from other associated with my health care to allow management of my current and ongoing health. I consent to the collection of my personal information for administrative and billing purposes, including compliance with Medicare Australia and the Health Insurance Commission. I acknowledge that on occasion there may be a need to contact me, I permit the use of telephone numbers and email address that I have provided above. By providing these contact details, I accept that a message may be left with the person answering these numbers or email address. If there are any changes to my personal details, I accept responsibility for informing the Managing Pain Clinic administration for any such change.
Terms and conditions
This practice policy outlines how personal information provided by yourself, referring Doctor or collected by Managing Pain clinic administration about you is used and managed. The Managing Pain clinic is bound by the National Privacy Principles contained in the Commonwealth Privacy Act and as directed by Health Privacy Principles in the Queensland Health Records. Managing Pain recognises and supports the right of all patients to privacy and confidentiality of their personal and medical records. Managing Pain clinic staff, as a condition of their employment have signed an acknowledgement undertaking not to discuss, disclose or utilise patient information other than in the performance of their administrative duties. To respect the confidentiality of all patient personal and medical information, as well as the privacy of individuals, it should be noted that all patient information/records are securely, electronically stored in the patients personal file. The type of information collected and retained by Managing Pain includes personal information, sensitive health records and medical information from third parties. The collection of patient information is necessary to provide an accurate assessment on consultation followed by presentation of the recommended care management plan, to allow all patients the opportunity to move forward with their health rehabilitation. Personal information relating to a persons’ racial or ethnic origin, religion, sexual preference, criminal record together with their health information is sensitive and will be used and disclosed only for the purpose for which it was provided or directly related secondary purpose, unless you agree otherwise, or the use of disclosure of the sensitive information is allowed by law. Disclosure may also be to the medical or allied health care providers, government departments and anyone else that you authorise Managing Pain to release information to. Patient medical reports that are required to be forwarded to relevant third parties, including medical and/or allied health persons and/or Workcover case managers are forwarded securely by Medical Objects or efax if available. Patients should note that they are responsible to ensure that all personal contact information provided to Managing Pain is accurate and kept up to date. Patient information can be updated during Managing Pain office hours.
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