Authority to Share Information (Form-1058)

AUTHORITY TO SHARE INFORMATION (Form-1058)
Participant's Details
Name*

First NameLast Name
Date*

DayMonthYear
Date
I, the undersigned, do hereby grant permission to Australian Quality Care to collect and disclose information which is relevant to the support services provided. I understand throughout the provision of my regular and ongoing support, AQCare will use this consent as authority to collect and disclose my information to/from relevant third parties and agencies required to provide these support services.

AQCare may disclose my personal information to:
- AQCare related entities to facilitate internal business processes
- Commonwealth and State departments and agencies which provide funding for services (i.e. NDIS Auditing purposes, Office of Public Guardian, Public Trust, NDIA)
- Contractors and/or agencies who provide on behalf of AQCare
- Your NDIS registered Support Coordinator and/or your Plan Manager
- Other NDIS service providers who offer supports (i.e. Centacare, Endeavour)
- Health and allied health professionals who provide specialist support to facilitate the delivery or support services (i.e. GP, physiotherapist, hospitals)
- Third parties including Queensland Police Service, to help with identification in the case of missing persons, and
- Emergency medical and ancillary staff in an emergency.
I understand that it is my right to choose if specific organisations are excluded from accessing or receiving information AQCare holds about me. Therefore, by indicating in writing below, I DO NOT give authority to AQCare to contact or disclose my information to the following:
Signature of Participant

*Or signature of person acting on authority under Guardianship Administration Act 2000 or Powers of Attorney Act 1998 for the person named above, OR an Informal Decision Maker (must have an Informal Decision Maker Details Form-1066 signed) for the person named above.
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
In the presence of (Witness)
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

AUTHORITY TO SHARE INFORMATION (Form-1058)

Participant's Details

Signature of Participant

In the presence of (Witness)