Consent to Share Information Form

Please complete and submit this form.

Consent to Share enables a client or authorised representative to give permissions for Health Assure employees to discuss personal and plan information over the phone, via email or face to face with additional parties such as:

• Additional contacts ie family members such as parents, siblings, extended families and close friends etc.
• Support Coordinators.
• Service Providers.

Only yourself (the Health Assure Participant), your Guardian or Authorised Representative may give consent to share.

The information that can be shared includes your current budgets, information about recent invoices and providers that you have engaged with, client details and representative contact details. You can tell US the level of consent that you would like someone to have.

Giving additional parties consent to access your information is purely optional and will not affect your services with us. You can add and remove people from your Consent to Share list at any time.

Health Assure Participant:

Person completing this form:

Additional contact person details: (if required):

Additional contact person details: (if required):

Support Coordinator details: (if applicable)

Authority and Declaration

 

I declare that I have the authority to approve this consent to share form in the following capacity as (please circle) The Authorised Representative / Guardian

If you wish to remove any Authorised Nominees, please contact us so we can update our records. Until such time we are notified, Authorised Nominees will remain on file.

Thank you for choosing Health Assure Plan Management as your NDIS Plan Manager. We look forward to supporting you.

If you have any questions, please visit our website for information or contact us on 1300 545 095 or via email hello@healthassure.com.au