Privacy Act Consent Form

Privacy Act Consent Form

Victorian Orthopaedic Spine Service is committed to protecting the privacy and security of any personal information it obtains about individuals and recognises that it must adhere to the provisions of the FEDERAL PRIVACY ACT. We require your consent to collect personal information about you. Please read this form carefully, and sign where indicated below.

Victorian Orthopaedic Spine Service collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your healthcare needs.

This means we will use the information you provide in the following ways:

  1. Administrative purposes in running our 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, specialists and allied health practitioners outside this medical practice. This may occur through referral to other doctors, specialists, allied health professionals or for medical tests and in reports returned to us following the referral.
  4. Disclosure to other doctors, specialists and allied health professionals in the practice for the purpose of continuity of patient care.
  5. For disclosure to visiting doctors, allied health professionals and medical students for the purpose of patient care and teaching.
  6. Disclosure for the purpose of research and quality assurance activities to improve individual and community health care and practice management. Usually no individual names will be recorded but if this is not the case, you will be informed when such activities are being conducted and given the opportunity to ‘opt out’ of any involvement.
  7. For quality review of the practice, medical records may need to be assessed by a visiting doctor.

I have read the information above and understand the reasons why my information must be collected. I am also aware that Victorian Orthopaedic Spine Service has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information requested of me, but 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 a reasonable explanation in these circumstances. I consent lo the handling of my information by Victorian Orthopaedic Spine Service for the purposes set out above, subject to any limitations on access or disclosure that I notify in writing to Victorian Orthopaedic Spine Service.

There are some circumstances where information needs to be disclosed without consent ie:

  • An emergency situation
  • Where disclosure is necessary to lessen or prevent a serious and imminent threat to an individual’s life, health or safety or is a serious threat to public health or safety.
  • Where disclosure is a legal requirement eg communicable disease, suspected abuse, subpoena to court
  • For medical indemnity insurance.