New Patient Information

New Patient Information

Macarthur Surgical Group
My appointment is with which doctor?
Title
Full Name*

First NameLast Name
Middle Name (optional)
Preferred Name (optional)
First Name
Maiden Name (optional)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
DAY/MONTH/YEAR
What is your gender?*
Pronouns
Mobile Number*
I agree to receive SMS reminder messages
Home Phone
Work Phone
Email Address
example@example.com

Medicare Card Number
Please add the 10 numbers only listed on your Medicare Card
Individual Reference Number (IRN)*
eg 01
Expiry Date*
MMYYYY
Do you have PRIVATE Health Insurance
Name of Fund*
eg BUPA/HCF/AHM
Membership Number*
Fund Reference No *
Member Name*

First NameLast Name
Do you hold a DVA card (Department of Veterans Affairs)? (original card to be verified at appointment)
DVA File Number
e.g. QSS12345
Card Type (Colour)
Membership Expiry Date
MMYYYY
Name on Card

First NameLast Name
Do you hold an AGED PENSION CARD? (card will be verified at appointment)
PENSION Concession Card Number
CRN Number (include the letter at the end)
Expiry Date
DDMMYYYY
Do you hold a DISABILITY SUPPORT PENSION? (card will be verified at appointment)
HEALTH CARE Card Number
Expiry Date
DDMMYYYY
Emergency Contact

First NameLast Name
Mobile Phone
Please enter a valid phone number.
Relationship
Are they your next of kin
Do you require a translator
If so, which language
Indigenous Status (tick which applies)

	Add Details
Drs Name
Type (eg Cardiologist)
Suburb
(next if applicable)
Drs Name
Type (eg Cardiologist)
Suburb
(next if applicable)
Drs Name
Type (eg Cardiologist)
Suburb

PRIVACY POLICY PATIENT CONSENT FORM
Dear Patient,

We require your consent to collect personal information about you. We collect information from you, including your personal details and full medical history, for the primary purpose of providing you with accurate quality health service. We will use the information you provide in the following ways:

- Administrative purposes in the running of our medical practice: including pre-operative and post-operative calls using phone numbers and names you provide us, as well as hospital interactions for booking surgical services

- Billing purposes, including compliance with Medicare and Health Insurance Commission requirements

- Disclosure to others involved in your medical care, including treating doctors, specialists and hospital staff outside this practice. This may occur though referral to other doctors, surgery at the hospitals, for medical tests and in the reports or results returned to us following the referrals. If necessary, we will discuss this with you.

- Disclosure to other doctors in the practice and registrars attached to the hospitals for patient care and teaching. Please let us know if you do not want your records accessed for these purposes.

- Disclosure for research and quality assurance activities to improve individual and community of health care and practice management. You will be informed when such activities are being conducted and given the opportunity to “opt out” of any involvement.

Important

- I have read the information above and understand the reasons why my information must be collected

- I am aware that this practice has a privacy policy on handling patient information

- I understand that I am not obliged to provide any information requested but failure to do so might compromise the quality of health and treatment provided to me

- I am aware of my rights to access the information collected about me, except in circumstances where access might legitimately be withheld. I understand that I will be given an explanation in these circumstances.

- I understand that if my information is to be used for any other purpose other than that set out above, my further consent will be obtained

- I consent to the handling of my information by this practice for the purpose set out above, subject to any limitations on access or disclosure that I notify this practice of.
Signature*

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Date*

DayMonthYear
DDMMYYYY

INFORMED FINANCIAL CONSENT - FEE POLICY
Consultation

To cover the costs of running the rooms, charges a fee will apply for your consultation. If eligible, you will receive a rebate from Medicare. Your consultation is not covered by your private health insurance as it will only cover inpatient services.

Gap Payments

Our specialists participate in Known Gap Cover arrangements with all major health funds. This means that patient out of pocket expenses (i.e. the Gap) will be capped to a certain amount. The exact Gap amount may differ depending on your procedure. Gap payment details will be advised at the time of procedure booking. It is the responsibility of the patient to ensure their health fund covers any advised procedure costs. Any costs not covered by the health fund will be payable by the patient.

Please note that this applies to services provided by Macarthur Surgical Group specialists only. There may be other fees for services provided by other specialists (anesthetists), surgical assistant, associated services (e.g. pathology and radiology), your health fund (e.g. excess) or the hospital.

We will endeavor to inform you of the anesthetist that will be involved in your surgery so you can make enquiries regarding his/her fees.

Payment Options

Cash - this can only be made in person at our rooms

EFTPOS / Credit Card (Visa / Mastercard only/Debit Card) - please call our rooms to provide your card details. Surcharge fees apply

EFT Transfer (surgical payments only) - you may transfer electronically at your convenience. Please quote your surname and invoice number. Please contact the rooms regarding account details for direct debit if you do not have them. Please note that we do not accept personal cheques.

Late Payment

Please attend to the invoice promptly when received. Outstanding invoices after 2 months will be referred to external account recovery services. The fee charged by external agencies (usually 20% plus GST of the account balance) will be added to the account. We will endeavour to contact you prior to this but it remains your responsibility to pay the invoice.

Financial Difficulties

Please contact the rooms to discuss alternate payment arrangement if you are in financial difficulty. I have read and understood the above fee policy. I can request a copy of this policy for my records.
Signature*

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New Patient Information

HEALTH TEAM MEMBERS

Specialists

PATIENT HEALTH QUESTIONNAIRE

PRIVACY POLICY PATIENT CONSENT FORM

INFORMED FINANCIAL CONSENT - FEE POLICY