• Consent & Privacy Acknowledgment Form

    Consent & Privacy Acknowledgment Form

    (In accordance with the Protection of Personal Information Act, 2013)
  • Consent and Acknowledgement for Visual Screening & Research

    By signing this form, you acknowledge and consent to the following:
  • Definitions

    Dependant: Spouse, partner, children, or other family members for whom the patient is responsible, or any other person recognized as a dependant.
    Practitioner/Student Practitioner: The supervisor(s) and student(s) receiving training at the clinical facility. 
    Patient: The individual receiving healthcare or their legal guardian.
    Personal Information: Information that identifies or relates to the patient, including health, medical, and identification information.
    POPI: Protection of Personal Information Act, 4 of 2013.
    Consent for Processing By agreeing to these terms, the patient consents to sharing their personal information with:

    • Medical scheme/ funding provider
    • Parents/guardians if the patient is a minor
    • Pathologists, ophthalmologists, and other healthcare providers
    • Other optometrists, opticians and opticianry students 
    • Authorized staff members/service providers
    • Regulatory and auditing authorities 

    Maintenence of consent: 

    Changes to Terms: Patient will be notified within 30 days of any changes to these terms.
    Correction of Information: It is the patient’s responsibility to update any changes to their personal information.
    Consent Management: Patients can contact the clinical manager on duty to manage or withdraw consent.


    POPI Compliance

    Purpose: The patient’s information will be used for:

    • Sharing with medical scheme/ funding providers, healthcare partners, and service providers
    • Storing and processing of health data securely for purposes of patient management and clinical training of students 
    • Clinical training of opticianry students 
    • Research data (according to ethical considerations and further consent) 
    • Invoicing, payments, and refunds

    Consequences: Personal information will be shared only with authorized parties, and reasonable steps will be taken to ensure privacy and security.

    Right to withdraw consent 

    Patient may revoke consent for sharing their personal information with any party by notifying the clinic supervisor. Upon revocation, personal information will no longer be shared.


    Storage and Retention

    Personal information will be stored securely in compliance with POPI and data protection laws.
    Retention period will follow statutory limits and be deleted/destroyed thereafter.


    Patient Acknowledgment

    Patient consents to the use and processing of their or their dependent’s personal information as outlined in these terms.
    Patient has had the opportunity to read, understand, and ask questions about the consent form.

     

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