New Patient Form

New Patient Form

Patient Information

Emergency Contact Person/Next of Kin

DASS 21

Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me a considerable degree, or a good part of time 3 Applied to me very much, or most of the time

Terms and Conditions

  1. I accept that payment in full is required is at the time of consultation.
  2. I accept that if an account remains unpaid, no further medical services will be provided.
  3. I accept that payment of a non-attendance fee is an obligation to be a patient at this practice.

Privacy and contact consent

This practice has produced a Privacy Policy that outlines the way we collect and use your information and how you can access that information. Please read the information below before submitting

Introduction:

We are committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Privacy Act 1988 (Commonwealth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy Principles and relevant State and Territory privacy legislation (referred to as privacy legislation).

This Privacy Policy explains how we collect, use and disclose your personal information, how you may access that information and how you may seek the correction of any information. It also explains how you may make a complaint about a breach of privacy legislation.

This Privacy Policy complies with all applicable guidelines, codes of conduct, and laws relating to privacy and confidentiality. From time to time, we may make changes to our policy, processes and systems in relation to how we handle your personal information. We will update this Privacy Policy to reflect any changes.

Collection:

We collect information that is necessary and relevant to provide you with medical care and treatment, and management of our medical practice. This information includes your name, address, date of birth, gender, health information, family history, and contact details. This information may be stored on our secure computer medical records system.

Wherever practicable we will only collect information from you personally. However, we may also need to collect information from other sources such as treating specialists, radiologists, pathologists, hospitals and other health care providers. We collect information in various ways, such as over the phone or in writing, in person in our practice or over the internet if you transact with us online. This information may be collected by medical and non-medical staff. In emergency situations we may also need to collect information from your relatives or friends.

We are required by law to retain medical records for certain periods of time depending on your age at the time we provide services.

Use and Disclosure:

We will treat your personal information as strictly private and confidential. We will only use or disclose it for purposes directly related to your care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment. For example, the disclosure of blood test results to your specialist or requests for x-rays. There are circumstances where we may be permitted or required by law to disclose your personal information to third parties. For example, to Medicare, Police, insurers, solicitors, government regulatory bodies, tribunals, courts of law, hospitals, or debt collection agents. We may also from time to time provide de-identified statistical data to third parties for research purposes with approved privacy policies.

We may disclose information about you to outside contractors to carry out activities on our behalf, such as an IT service provider, solicitor or debt collection agent. We impose security and confidentiality requirements on how they handle your personal information. Outside contractors are required not to use information about you for any purpose except for those activities we have asked them to perform.

Data Quality and Security:

We will take reasonable steps to ensure that your personal information is accurate, complete, up to date and relevant. For this purpose, our staff may ask you to confirm that your contact details are correct when you attend a consultation. We request that you let us know if any of the information we hold about you is incorrect or out of date.

Personal information that we hold is protected by:

  • securing our premises;
  • placing passwords and varying access levels on databases to limit access and protect electronic information from unauthorised interference, access, modification and disclosure; and
  • Security training is conducted with all staff – personal signed document is signed by all employees stipulating the confidentiality requirements.

Corrections:

If you believe that the information, we have about you is not accurate, complete or up-to-date, we ask that you contact us in writing (see details below).

Access:

You are entitled to request access to your medical records. We request that you put your request in writing and we will respond to it within a reasonable time.

There may be a fee for the administrative costs of retrieving and providing you with copies of your medical records.

We may deny access to your medical records in certain circumstances permitted by law, for example, if disclosure may cause a serious threat to your health or safety. We will always tell you why access is denied and the options you have to respond to our decision.

Complaints:

If you have a complaint about the privacy of your personal information, we request that you contact us in writing. Upon receipt of a complaint, we will consider the details and attempt to resolve it in accordance with our complaints handling procedures.

If you are dissatisfied with our handling of a complaint or the outcome you may make an application to the Australian Information Commissioner or The Tasmanian Office of the Ombudsman and Health Complaints Commissioner.

Overseas Transfer of Data:

We will not transfer your personal information to an overseas recipient unless we have your consent or we are required to do so by law.

Contact:

Please direct any queries, complaints, requests for access to medical records to:

Attn: The Practice Manager
The Bubble Launceston
4/23 Brisbane Street
Launceston, TAS, 7250

This consent form covers collection and use of your information (including your Government issued Individual Health Identifier) to provide comprehensive, co-ordinated and continuing whole person medical care. As outlined in the Privacy Policy, your information may be disclosed to other health care professionals to provide this level of care. In addition, there are circumstances when information has to be disclosed such as:

  • Emergency situations
  • Public health statutory requirements on notifiable diseases
  • Medical indemnity insurance obligations
  • Provision of information to Medicare or private health funds for billing and rebate purposes
  • Quality assurance purposes

I consent to participate in The Bubble Launceston’s scheduled reminder system for cervical screening, intrauterine device or contraceptive implant replacements. I also consent to being contacted for review of test results as may occur from time to time.

If you have had any pathology, imaging, or other testing done through The Bubble Launceston, we will contact you regarding the results if the doctor advises it needs a follow up. We strongly advise and would be in your best interest that you ring to follow up your test results within the time frame advised by your GP.

I consent to have SMS appointment reminders and recalls sent to my disclosed mobile phone number. I consent to allow messages identifying the surgery as the caller.

We feel that the above measures are a fundamental part of the high-quality healthcare and we strive to give to all our patients. To aid this it is essential we have your most recent contact details and that you advise the practice of any changes.

Separate and specific consent is required if your information is to be used for research or statistical purposes, or if any third party eg. insurance company, workers compensation, or employer requests your medical information. By signing this consent form, you acknowledge that you have read and you agree to your information being collected and used as described above.

I have read and understood the Privacy Policy provided by this practice and I consent to the collection and use of my information as described in the Privacy Policy. I also agree to participate in this practice’s recall and reminder systems.

As part of providing a psychological service to you, Amy Farrell needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment, is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service to you. A more detailed description is provided in The Bubble’s Privacy policy.

Consequence of not providing personal information

If you do not wish for your personal information to be collected in a way anticipated by this letter or the Privacy Policy, Amy Farrell may not be in a position to provide the psychological service to you. In most cases it will not be possible for you to be anonymous or to use a pseudonym.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The psychologist may discuss with you different possible forms of access.

Disclosure of personal information

All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when:

  1. Is subpoenaed by a court, or disclosure is required or authorised by law; or
  2. Failure to disclose the information would in the reasonable belief of Amy Farrell/The Bubble Launceston place you or another person at serious risk to life, health or safety; or
  3. Your prior approval has been obtained to:
    1. Provide a written report to another professional or agency (e.g. a GP or a lawyer); or
    2. Discuss the material with another person (e.g. a parent, employer, health provider or third party funder); or
    3. Disclose the information in another way; or
    4. Disclose to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected.

Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented, or disclosed for any other purpose. In the event that unauthorised access, disclosure or loss of a client's personal information occurs, The Bubble will activate its data breach plan and use all reasonable endeavours to minimise any risk of consequential serious harm.

I have read and understood this consent form. I agree to the above conditions for the psychological service provided by Amy Farrell.