Consent Form
Provide your details and consent to share personal and health information for coordinated care.
Full Name
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Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
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Please Select
Male
Female
Non-binary
Prefer not to say
Other
Service Start Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
NDIS Number
Notes
Participant Representative (if applicable)
Personal / Health Information to Be Shared
List each service or provider with whom information may be shared.
Services/Providers to Share Information With
Consent to Share Information
Please review the consent statements and provide your agreement.
Consent Statements
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I understand that the recommended services may require FREEDOM INDEPENDENCE CARE to provide relevant information about me to the organisations delivering those services.
I understand that FREEDOM INDEPENDENCE CARE must follow all applicable privacy legislation, and I will notify the organisation immediately if I believe my privacy has been breached.
I acknowledge that FREEDOM INDEPENDENCE CARE will securely store my information and will not release my documents to anyone other than the services listed above.
The organisation has explained why certain information about me may need to be shared with other service providers and how this supports my care.
I give permission for my information to be shared with the individuals or agencies identified above for the purpose of coordinating my support.
I agree that authorised auditing bodies may access my file for the purpose of reviewing FREEDOM INDEPENDENCE CARE’s quality and compliance processes.
I consent to FREEDOM INDEPENDENCE CARE collecting audio or visual recordings of me, or on my behalf, when required for service delivery or documentation.
Inform participants about the purpose of information collection, use, and disclosure, including circumstances where information may be disclosed without consent as required or authorised by law.
Signature
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Date Signed
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: