Patient Information Form

08 8267 3355 142 Ward Street, North Adelaide Mon - Fri: 9:00am - 5:00pm

patient information

Surname: (Mr/Mrs/Ms/Miss/Dr)

First Name:

Date of Birth:

Address:

Telephone: Home

Work

Mobile

Email:

Medicare No:

Ref No:

Exp:

Private Hospital Fund:

Membership No:

Extras only

(If extras only you will not be covered for your surgery)

Have you been in your fund for 12 months?:

Yes

** If NO you may not be covered for your surgery. Please contact your health fund to check.

Overseas Cover

Concession Card:

Aged

Disability

Other

Card No:

Exp:

Department of Veteran's Affairs:

Gold Card

White Card

Card No:

BUPA ADF Member

ID No:

DAN No:

Next of Kin:

Relationship:

Phone:

Emergency Contact:

Relationship:

Phone:

Workers Compensation / Third Party Insurance:

Claim No:

Employer:

Date of injury:

Case Manager:

Email:

Contact Number:

Financial Consent

I understand that medical expenses (including any gap payments) incurred as a result of consultation or surgical procedure with my Doctor at the Colorectal Surgery are my responsibility. If requested, I will pay my account in full and take full responsibility for claiming costs from the appropriate private health fund. All accounts are payable within 30 days of receipt. If it becomes necessary to use a Debt collection agency to recover monies owed by the undersigned, charges associated with said collection are also the responsibility of the undersigned. Please check with reception staff to confirm the procedures costs of gap payments that may be incurred.

Information about your medical and family health history is needed to provide adequate medical diagnoses and appropriate treatment. Medical care requires that each member of your medical team have full knowledge of your health information. To ensure the quality and continuity of your health care, your health information may be communicated via email and other forms of communication to/from health care providers and required recipients. For billing and medical rebate purposes information is provided to account administrators including Medicare, private health funds, hospitals, anaesthetists and assistant surgeons. This practice will at all times endeavour to protect your privacy in compliance with privacy legislation and our privacy policy (available on request).

Consent

I give my consent to my Doctor at the Colorectal Surgery and staff to collect, use and disclose my personal health information (via email and other forms of communication) for the purpose of providing the highest quality and continuity of health care in the expectation that this will be implemented as far as practicable in accordance with the privacy legislation and the privacy policy of this practice. In order to arrange operations, tests, or other medical appointments, we need to provide information to other health care providers.

The Federal Government's 'My Health Record' system allows health practitioners to upload patient information to a website that can be seen by others involved in a patient's health care. Colorectal Surgery uploads its patient data to this website as we believe that it is an important component of providing comprehensive care. All patient's are entitled to request that their information not be shared in this fashion.

My Health Record- Please do not send my clinical information to 'My Health Record'

Yes