CFH - Consent to Collect and Use Information GWH-020-13.1

Consent to Collect & Use Health Information
Child & Family Health

Please select which service you are providing consent to:

Name of Referred Child

Date of Birth

Consent to Collect & Use Information

Gateway Health collect, store, and use your information in accordance with the Australian Privacy Principles and Health Privacy Principles.

Further Gateway HealthPrivacy Information is available at https://gatewayhealth.org.au/patients-clients/privacy/

First Name *

Last Name *

Date of Birth *

I agree that Gateway Health can set up and keep a health care record for me *

I agree that all Gateway Health staff involved in my care can access relevant componenets of my health record, to assist in providing the best possible care *

I understand that information may be given to funders of the service, or be used for research and quality assurance activities, subject to confidentiality and privacy provisions of state and federal law *

I agree that my contact details may be shared with the Department of Health and their contractors for quality improvement activities *

I understand that Gateway Health may be required by law to share my information to a third party without my consent for mandatory reporting reasons as outlined in the privacy brochure *

I have read the Gateway Health Privacy Information and understand my right to apply for access to my information *

When needed, I agree to participate in telehealth consultations (including phone and video) using a secure platform, and understand that neither party may record the consultation without prior consent

YesNo

I agree to share and receive personal health information via electronic submission, e.g.via email or text message, and understand that this may not always be secure

YesNo

When needed, I agree for photographs or videos to be recorded, stored and used to support my health care; e.g. home environment, group activities and understand that these will be held securely. *

YesNo

Signature *

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Person Signing Form: *

I am the ClientI am the Parent/CarerI am an authorised person signing on behalf of the client

Parent/Carers Full Name *

Parent/Carers Contact Number or Email *

Authorised Person Name *

Authorised Person Relationship to Client *

Contact Phone Number/Email: *

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