Ballarat Sports Medicine Patient Registration

BallaratOSM Pty Ltd, their partners and staff are committed to the protection of your privacy. We require you to provide 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 that 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, through 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 referrals.

> Disclosure for research and quality assurance activities to improve individual and community health care and practice management. (Individuals are not identified in these circumstances.)

> X-rays and de-identified clinical photographs may be used for teaching 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 the handling of 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 understand that if my information is to be used for any other purpose other than that set out 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.