Please Note:

• If you are completing a referral on behalf of a client who is not present to sign the Privacy and Consent form please proceed directly to the referral form. Our referral form incorporates our Privacy and Consent form as part of our commitment to protecting your privacy.

The Potential Ability Group, are committed to ensuring all our clients are fully informed in the information we may require, how we use and store all client information, how clients may access and correct their information, how clients may withdraw or amend their prior consent, and in obtaining permission to disseminate any information.

Privacy and Confidentiality: The legal and ethical right to have private and personal information treated in confidence.

The Potential Ability Group staff respect every client’s right to privacy and this document has been written to advise you on how we treat the information we receive about a client. In order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you. To provide a high-quality service, The Potential Ability Group need to obtain information that can sometimes be of a personal nature.

The Potential Ability Group endeavour to ensure that information collected is accurate and complete. You can amend any information that requires correction or updating, or remove and/or amend your consent at any time whilst it is held by The Potential Ability Group by contacting us in writing at:

• The Potential Ability Group
  PO Box 803
  McLaren Vale, SA 5171
• Or via email at office@potentialabilitygroup.com.au.

When an individual is unable to provide consent to the collection, use and disclosure of their personal information we will gain written permission on an individual’s behalf from their guardian or carer. If some personal information is not able to be collected, we may be unable to provide certain services. Please note you are able to refuse consent for storage of some personal information below if required.

Personal Information we require includes, but is not necessarily limited to the following:

• The client and caregiver’s names, address and contact telephone number;
• Details of any medical practitioners/health professionals involved in the client’s care;
• Information regarding the client’s current health/medical history;
• Reason for referral of the client to The Potential Ability Group;
• Details of the educational/care facility where the client is currently/was previously in attendance;
• Some financial information and health insurance details.
• Evidence of clearances from SA Health in relation to COVID-19 or other pandemic diseases.
• Funding scheme numbers/eligibility.

Agencies we may need to contact on your behalf include but is not necessarily limited to the following:

• Medical providers
• Other health care providers
• Equipment suppliers
• Government departments
• Regulatory bodies

You can be assured that your privacy will always be protected in accordance with Privacy Legislation (Privacy Act 1988 Any information provided to us is kept on file in a secure/locked location. All information held on a computer is password protected. Some of this information may be given to government agencies where particular laws require its collection, such as Emergency Services, the NDIS Quality & Safeguards Commission or Child and Abuse Reporting Line, or where there may be a serious threat to the life or health of any person. Written information and electronic data will be destroyed after legal obligations to retain it have expired. All files stored online are encrypted and kept in secure storage servers which are in data centers in Sydney and in Western Australia.

Please note that our primary method of communication is via email. We will ensure that the email subject and content have the least amount of identifiable information in them while still being practical for the recipient, to ensure minimal risk for clients.

All forms of written communication involve an element of risk that information could be read by someone other than the intended recipient. The potential risks of using unsecured or unencrypted email include:

• Emails can easily be sent to the wrong recipient;
• Email is often accessed on portable devices, such as smart phones, tablets and laptops, which are easily lost or stolen (please note all devices are password protected);
• Emails can be forwarded or changed without the knowledge or consent of the original sender;
• Email is vulnerable to interception.

You may request access to your personal information at any time. You may also register a complaint regarding information we hold which you believe to be incorrect. Such requests must be either:

• In writing and addressed to the Privacy Officer at The Potential Ability Group, PO Box 803 McLaren Vale, SA 5171, or
• By emailing privacyofficer@potentialabilitygroup.com.au, or
• By calling The Potential Ability Group Privacy Officer via (08) 7200 3216

Please include reasons why you wish to access these records and/or why you feel the information is incorrect. We will not charge you to access/make changes to these records, however you may be charged for any copies taken. Requests will be assessed as required by law and we will advise you of the reasons if access is denied.

Should a reportable incident occur, each participant, and with the participant’s consent, their support network, the providers implementing behaviour support plans and other stakeholders will be included in the review of incidents and notified of the outcome, as applicable.

TPAG is passionate about supporting the next generation of OTs and quality service provision, so you will likely have a student or senior clinician shadowing your OT at some point. You will be provided the option to opt out of this on the referral form or at any time by calling the office on 7200 3216.

You can find a copy of our ‘Privacy & Confidentiality Statement’:

• In this Handbook, or;
• On our website potentialabilitygroup.com.au/privacy-statement/

‘Personal information’ (as outlined in the ‘Privacy and Confidentiality Statement’ from The Potential Ability Group will be treated in a confidential and professional manner. The Potential Ability Group is prohibited from the release of personal information without consent. The Potential Ability Group will not disclose your personal information to overseas recipients.

I ___________________ (Name of person providing consent) consent to the release and exchange of personal information by staff of The Potential Ability Group to other Health Service Providers involved in the care of the client ___________________ (Name of the client) this is to ensure staff can make an accurate assessment of the client’s needs and provide services as required and includes both written and visual information (i.e. photographs for assessment and therapy purposes).

I understand:

1. The reasons for the collection of personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure.
2. That it is my choice as to what information I provide, and that withholding or falsifying information might act against the best interests of the client’s assessment and therapy progress.
3. Personal information may be used for statistical and audit purposes by The Potential Ability Group.
4. Case notes may be stored in a common file and may be read by other The Potential Ability Group staff.
5. That to provide adequate continuity of care, personal information may be accessed and transferred between The Potential Ability Group clinicians and/or other professionals (e.g. the client’s Doctor, other Allied Health or educational professionals).
6. That I can access the personal and treatment information relating to the client on request and if necessary, correct information that I believe to be inaccurate. I am aware and I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me.
7. In the event debt collection services are actioned, my contact details and billing information will be provided, and I will incur the associated administration fee.

I have been provided with or have been given an opportunity to obtain a copy of the following;

1. Information detailing fees, including cancellation, which may be incurred for The Potential Ability Group services (where applicable);
2. The Potential Ability Group ‘Privacy and Confidentiality Statement’.

Telehealth Consent:

We are now offering our services via telehealth methods, which can be via phone or video conference, using the 8x8 online platform. Evidence has shown that outcomes are consistent across telehealth and face to face interventions. By utilising telehealth as a delivery model of services we can support clients in a safe manner at times of illness or when other factors may impact the ability for a face-to-face session to take place.

The benefits of having a telehealth consultation can be:

• Eliminating the risk of infection while still being able to receive Occupational Therapy services.
  No travel charges associated with a visit.
• Providing consistency and support during unprecedented isolating times, such as a pandemic.
• Continued progression towards your goals - where the hold on face-to-face supports has an unknown longevity.

The risks to consider around telehealth consultation include that:

• A video consultation will not be exactly the same and may not be as complete as a face-to- face service.
  There could be some technical problems that affect the telehealth consultation.
• The Potential Ability Group uses systems that meet recommended standards to protect the privacy and security of the telehealth consultation. However, the service cannot guarantee total protection against hacking or tapping into the session by outsiders. This risk is small, but it does exist.
• If the video or phone session does not achieve everything that is needed, then you will be given a
• choice about what to do next. This could include a follow up second telehealth session.

You can change your mind and stop using video or phone consultations at any time, including in the middle of a session. This will not make any difference to your rights to ask for and receive health care.

I have read, understood and agree to all of the above information. I acknowledge that I understand that:

• This can be read through to me over the phone if required;
• There is a large print copy available upon request;
• This document can be provided to me electronically or via Australia Post as requested;
• If any information remains unclear or I require clarification, additional explanation can be provided by phoning the office on (08) 7200 3216.

Title: TPAG Privacy and Confidentiality Statement + Consent to Obtain and Release Information

Doc No: TPAG01

Version: 16