Patient Proforma

This document begins the process of collection of your information for the following purposes:
i. Health information to assist in the management of your care
ii. Administration of this medical practice
iii. Billing, including compliance with Medicare and Health Insurance Commission requirement
iv. Disclosure to others involved in your health care, including doctors and specialists outside this practice who may become involved in treating you. This may occur through referral to other doctors and specialists outside this practice who may become involved in treating you. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals. If these providers share your information with us, this will also form part of your file.
v. Disclosure for research and quality assurance activities to improve individual and community health care and practice management.
vi. We may share the collected information with other health providers that have treated you, or may treat you in the future, for eg your GP.
I have read the above information and understand why collecting this information about me may be necessary. I am also aware that this practice has a privacy policy on handling patient information.
I understand that if my information is to be used for any other purpose other than set about above, my further consent will be obtained. I acknowledge that I have read this form before signing it and that a member of the staff of this practice has at my request clarified any aspects of it that I did not understand at first.