Hervey Bay Patient Questionnaire

Health Information Collection and Use Consent Form

Please read this consent form carefully, and sign where indicated below.

As a patient of our medical practice we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. We aim to protect the privacy and secure storage of your health information in accordance with the Privacy Act. You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information. We require your consent to collect personal information about you and to use the information you provide in the following ways:

• Deliver the health services and treatment to the patient.
• Administrative purposes in running our medical practice.
• Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
• Disclosure to others involved in your healthcare including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
• Disclosure to other doctors in the practice, locums, etc. attached to the practice for the purpose of patient care and teaching.
• Comply with any legislative or regulatory requirements eg notifiable diseases.
• For reminder letters which may be sent to you regarding your health care and management.

COMMUNICATION BY EMAIL: Dr Mastakov and his staff are required by law to protect the privacy of your personal and health information. However, in our modern society most people expect to communicate in the most efficient way available and this usually involves the use of emails. Email transmissions are not secure and there is a risk that emails and their attachments may be intercepted and read by others. By providing your email address and signing this form, you are acknowledging that, while we will do our best, we cannot ensure that any emailed information or attachments will remain private and secure. You are also giving Dr Mastakov and his staff permission to communicate with you by email and to forward information and documentation to you by email. We will use the email address you have provided to us until such time as you provide us with an alternative email address