Welcome to Station Road Medical Centre Booval Ipswich
To enable ongoing care and total quality improvement within this practice, and in keeping with the Privacy Act 1988 and Australian Privacy Principles (APPs), we wish to provide you with sufficient information on how your personal health information may be used or disclosed and record your consent or restrictions to this consent.
Our doctors and staff are required to sign a confidentiality agreement at commencement of working at the practice, and are also given training in this area at induction, so that they understand how to protect your privacy. Your personal health information will only be used for the purposes for which it was collected or as otherwise permitted by law and we respect your right to determine how your personal health information is used or disclosed.
The information we collect may be collected by a number of different methods and examples may include: medical test results, notes from consultations, Medicare and health insurance details, data collected from observations and conversations with you, and details obtained from other health care providers (e.g. specialist correspondence) or third parties. Your health information can also include information that you provide to us regarding your social and family history because it is relevant to your ongoing health management.
By signing below, you (as a patient/guardian) are consenting, that on obtaining your personal health information it may be used or disclosed by the practice for the following purposes:
Your may contact the Privacy Officer at Station Rd Medical Centre, with any questions or concerns by phoning or writing to:
The Privacy Officer
Station Rd Medical Centre
50 Station Rd
07 3816 1155
At all times, we are required to ensure your details are treated with the utmost confidentiality. Your records are very important and we will take all steps necessary to ensure they remain confidential.
I, ___________________________ give my permission for my personal health information to be
collected, used and disclosed as described above, I understand only my relevant personal health
information will be provided to allow the above actions to be undertaken and I am free to
withdraw, alter or restrict my consent at any time by notifying this practice in writing.
Please note any restrictions to this consent that you wish to apply at this point:
Patient Name: (Please Print)
Signature: ______________________________ Date: ___________
Other family members (Each Patient 16 years or older must sign their own consent) you are signing this consent on behalf of:
Please give name and date of birth for each individual that this consent applies to:
If not Patient signing -Your name (Please Print ) __________________________________________
Your relationship to patient (e.g. Mother, Father, Guardian)__________________________________
PRACTICE USE ONLY: Witnessed by: (Staff Signature)____________________________________