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Participant Information Consent form

Participant Information Consent form

Authority to collect, hold, use and disclose participant information

  • Privacy Amendment Act

    Personal information collection, holding, use and disclosure of personal information by this organisation is protected by the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) (Privacy Act).

    Personal information is any information or an opinion that identifies you or could identify you and includes information about your health.

    The purpose for collecting personal information from you is to:

    • provide services, including planning, coordinating, funding, implementing, monitoring and reviewing our services
    • report to NDIS, government or other funding bodies of how funding is serviced by us,
    • take photographs and videos for therapeutic and marketing purposes
    • responding to your feedbacks, and
    • responding to your queries.

    * Please note that Rodgers Medical services TA Wraparoundkids is required to release information about service users (without identifying you by full name or address) to the Disability Services Commission and to the Australian Institute of Health and Welfare, to enable statistics about disability services and their participants to be compiled. The information will be kept confidential. This information is used for statistical purposes only and will not be used to affect your entitlements or your access to services. As a user of National Disability Agreement services you have the right to access your own files and to update or correct information included in the Disability Services National Minimum Data Set collection.

    This organisation will not disclose/use information about you for any secondary purpose unless:

    • You have consented to the use or disclosure; or
    • You would reasonably expect us to use or disclose the information for the secondary purpose as it is directly related to the primary purpose; or
    • The use or disclosure of the information is required or authorised by or under an Australian law or a court/tribunal order;
    • Rodgers Medical Services reasonably believes the use or disclosure is necessary to lessen or prevent a serious threat to life, health or safety of an individual or to public health and safety; or
    • Rodgers Medical Services has reason to suspect an individual may have done something unlawful or engaged in serious misconduct that relates to organisational functions or activities;
    • Rodgers Medical services reasonably believes that the use or disclosure is reasonably necessary to assist another person to locate a person reported as missing.

  • I give authority for Rodgers Medical services; to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs in accordance with the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) whilst I/we remain a participant of this organization.

    If my/our circumstances change I agree to notify Rodgers Medical Services as soon as practicable.

  • Date Format: MM slash DD slash YYYY
  • Signed By

  • Note: Where a participant does not have the capacity to give informed consent and does not have a legal guardian who has the authority to make decisions on behalf of the participant, the participant’s parent, family member or other person with a close personal relationship to the participant may sign this form. The person who signs on the participant’s behalf must print their relationship to the participant next to their name.

    Please send completed forms to Rodgers Medical services TA Wraparoundkids.

    Participant Consent for Third Party Release of Information

    Pursuant to The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and The Health Information Protection Act

    The purpose of this form is to provide consent to the release of personal information to third parties as requested by the Participant which is protected and governed by the privacy provisions of The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and The Health Information Protection Act.

  • (Print name of participant)
  • (Print name, title of person receiving information)
  • (Print name of participant)
  • (Print address and phone number of person receiving information)

  • Personal information which the organisation, or its staff need to release in order to respond to the following concern or issue:

    Information regarding

    I understand this may include personal information within the meaning of The Freedom of Information and Protection of Privacy Act, and personal health information within the meaning of The Health Information Protection Act.

    I further understand that the organisation will only release as much information as is needed to respond to my concern and subject to the restrictions and provisions of The Freedom of Information and Protection of Privacy Act 2012 (Cth) and The Health Information Protection Act.

    Consenting to the Release of Personal Information

    • In order to comply with privacy legislation, this consent is necessary when participants ask third parties to either advocate or make inquiries on their behalf regarding various issues or services provided by the organisation.
    • In all cases, the organisation will only release as much information as is needed in order to respond to the inquiry or participant’s concern.
    • Certain information will not be released by the organisation e.g. information about other individuals, records subject to solicitor-participant privilege, records relating to a current lawful investigation, records the release of which would affect the safety or health of anyone).
    • In the event a subsequent inquiry is made by the same third party which is unrelated to any previous participant concern, another consent form will need to be completed.
  • Signature of Person Consenting to Release
  • Date Format: MM slash DD slash YYYY