Patient Registration Form | Mole Check Clinic

Patient Registration Form

Patient Registration Form

    - -

    Patient consent form

    We require your consent to collect personal Health Information about you. Please read this information carefully, and sign where indicated below.

    Mole Check Clinic collects information from you for the primary purpose of providing quality health care. 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. This means we will use the information you provide in the following ways:

    • Administrative purposes in running our medical practice.
    • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
    • Disclosure to others involved in your health care, 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 the referrals.
    • Disclosure to other doctors in the practice, locums and by Registrars attached to the practice for patient care and teaching. Please let us know if you do not want your records accessed for these purposes, and we will note your records accordingly.
    • Disclosure for research and quality assurance activities to improve individual and community health care and practice management. You will be informed when such activities are being conducted and given the opportunity to “opt out” of any involvement.
    • Disclosure to other organisations where required by law or if necessary for debt recovery purposes.

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

    I understand that I am not obliged to provide any information requested of me, but that 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 be legitimately withheld. I understand I will be given an explanation in these circumstances.

    I understand that if my information is to be used for purposes other than those set above, my further consent will be obtained.

    I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.

    We expect payment on day of service.