Consent Form

1. MUST HAVE: At different times we might need your permission to gather information.
We might also need information about you so we can:
• (if you are not an NDIS participant yet) assist you to work out if you may become a
participant in the NDIS,
• prepare your plan and review your plan with you, if you become a participant,
• assist you in accessing supports outside the NDIS, and
• perform other functions as required under the NDIS Act.
• When we need to share your information with third parties, we will always show the third
party you have given your consent.

 We might need to use some of your info to speak to your plan manager or the NDIS.
Get you a better plan or find you the best possible services. Is that going to be okay with you?
2. MUST HAVE
Staff to read the ‘Primary Purpose Statement’
The primary purpose(s) of this service has been explained to me and I my personnal information to assist in achieving the primary purpose(s).

3. Proposed Use and Disclosure of my personal information
I understand that the following service(s) are recommended and relevant information about me
may be forwarded to the agency(s) that provide these services, in order that I receive the best
possible service.
4. When may information be disclosed without consent?
Emergencies, disasters and threats to life, health or safety
Personal information can be disclosed if it is necessary to lessen or prevent a serious and imminent
threat to an individual’s life or health. The NPPs also allow secondary use and disclosure if it is
necessary to lessen or prevent a:
• serious and imminent threat to an individual’s safety; or
• serious threat to public health or public safety.

By signing this Consent Form:
• I understand I can obtain further information about how the agency handles my personal
information from within the Privacy Policy. I can ask for a copy of the document.
• I understand I have given consent to ask for information about me and share my information
with third parties as listed
• I understand I can withdraw my consent at any time.
Pursuant to The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and The Health
Information Protection Act. The purpose of this form is to provide consent to the release of personal
information to third parties for the purpose of your care and support.
Conversational: You can ask us any time about what happens to the info we collect. Your privacy will
always be protected cos it’s the law. We only share what you say we can share, unless we think you
might be in danger. You can change your mind about it at any time, just ask us.