Please Note: It is the policy of Aesthetic Day Surgery to maintain strict confidentiality about all patients. The Privacy Act means that we need to have your permission to pass on some of your details to third parties as outlined below. This would occur only occasionally e.g. to the pathologist, anaesthetists etc...

PRIVACY ACT 1988

Patient Consent for Collection and Disclosure of Information

The Privacy Act 1988 requires hospitals and day surgery units to obtain consent from their patients to collect, use and disclose that patient's personal information.

Collection

This means that we will collect information that is necessary to properly advise and treat you. Such necessary information may include:

*full medical history;

*family medical history;

*medical photographs;

*ethnicity;

*contact details;

*Medicare/provide health fund details;

*genetic information; and

*billing/account details.

The information will normally be collected directly from you. There may be occasions when we will need to obtain information from other sources, for example:

*medical practitioners, such as GP's and specialists;

*other health care providers such as physiotherapists, occupational therapists, psychologists, pharmacists, dentists, nurses; and

*other hospitals and day surgery units.

Both our staff and the medical practitioners may participate in the collection of this information.

In emergency situations we may need to collect personal information for relatives or other sources where we are unable to obtain your prior express consent.

Use and Disclosure

With your consent, the staff will use and disclose your information, for purposes such as:

*account keeping and billing purpose;

*referral to a medical practitioner or health care provider;

*sending of specimens, such as removed skin lesions or swabs, for analysis;

*referral to another hospital for treatment and/or advice;

*advice on treatment options;

*the management of our day surgery;

*training and education, including patient education;

*quality assurance, day surgery accreditation and complaint handling;

*to meet our obligations of notification to our insurers;

*to prevent or lessen a serious threat to an individual's life, health or safety; and;

*where legally required to do so, such as producing records to court, mandatory reporting of child abuse or the notification of diagnosis of diagnosis of certain communicable diseases.

Access

You are entitled to access your own health records at any time convenient to both yourself and the day surgery.

Access can be denied where:

*to provide access would create a serious threat to life or health;

*there is a legal impediment to access;

*the access would unreasonably impact on the privacy of another;

*your request is frivolous;

*the information relates to anticipated or actual legal proceedings and you would not be entitled to access the information in those proceedings; and

*in the interests of national security.

We ask that, where possible, your request be in writing. We may impose a charge for photocopying or for staff time involved in processing your request. Where you dispute the accuracy of the information we have recorded you are entitled to correct that information. It is policy that we will take all steps to record all of your corrections and place them with your file but will not erase the original record.

Consent

I provide my consent for Aesthetic Day Surgery to collect, use and disclose my personal information as outlined above.

I understand that I am entitled to access my own health records except where access would be denied as outlined above.

I understand that I may withdraw my consent as to use and disclosure of my personal information (except when legal obligations must be met).

Patient Name:....................................................................................

Signed:................................................................................................

Patient/Parent/Guardian

Witnessed: ........................................................................................

Medical Practitioner/Staff Member

Date: ....................................................................................................

________________________________________________________

203B Patient Consent for collection and Disclosure of information - ADS

15 November 2001

Revision 1