Patient Registration and Consent - WorkCover or Third Party Insurance Claim

Patient Registration and Consent - WorkCover or Third Party Insurance Claim

FORM 3
Name*

First and Middle NameLast Name
Known As/Preferred Name:
Address*

Street Address

Street Address Line 2

CityState

Post Code
Date of Birth*

DayMonthYear
Phone Number*
Please enter a valid phone number.
Email
example@example.com
You have made an appointment with:

Dr Andrew CloutDr Angela HatfieldDr Simon MatthewsDr Morgan Prince
Medicare Card Number
Including Patient Reference Number (located on card next to name) - Eg. 0000 11111 2 3
Private Health Insurance

Fund NameMembership Number
Concession Card - Health Care Card (HCC) / Pension Card

Card Number Eg. 000 123 456HCard Expiry Date
General Practitioners (GP) Details

GP NameGP Practice
Next of Kin / Alternate Contact Details

Name and Relationship to YouContact Number

Employers Details*
Name of Company
Employers Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employers Phone Number
Please enter a valid phone number.
Insurance and Claim Details*
Name of Insurance Company
Claim Number*
Date of Injury*
Address of Insurance Company (PO or GPO Box preferred)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Insurance Company or Case Manager
Please enter a valid phone number.
Fax Number of Insurance Company or Case Manager
Please enter a valid phone number.
Email for Insurance Company or Case Manager
example@example.com

Thank you for choosing Riverina Orthopaedics as your healthcare provider. We are honoured by your choice and committed to providing you with the highest quality healthcare. We ask that you read our privacy and financial policies and acknowledge your understanding upon completion.

HEALTH INFORMATION COLLECTION and HOW WE USE IT

As a patient of our practice we aim to protect your privacy and provide secure storage of your health information. We require your consent to collect personal information about you and to use the information you provide in the following ways:
- Administrative purposes in running our medical practice
- Billing purposes, including compliance with Medicare and health Insurance Commission requirements
- Disclosure to others involved in your healthcare including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports and results returned to us following referrals
- Disclosure to other doctors in the practice, registrars etc. attached to the practice for the purpose of patient care and teaching
- For research and quality assurance activities to improve individual and community health care and practice management. Usually information that does not identify you is used but, should information that will identify you be required, you will be informed and given the opportunity to 'opt out' of any involvement
- To comply with legislative or regulatory requirements e.g. notifiable diseases
- For reminder letters which may be sent you regarding your health care and management
I have read the above and agree to the following:
- I understand the reasons why my information must be collected
- I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of care and treatment given to me
- I am aware of my rights to access information collected about me, except in some circumstances where access may be legitimately withheld. I will be given an explanation in these circumstances
- I understand that if my information is to be used for any other purpose than set out above, my further consent will be obtained
- I consent to the handling of my information by the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice
- I understand that my nominated next of kin is an emergency contact only and cannot be given my financial and/or medical information, without my verbal or written consent. I am aware that I must notify staff if a family member can access this information and my permission will be documented. I understand my preferences in this matter can change at any time and I must notify staff of these changes
FINANCIAL TERMS AND CONDITIONS

To ensure our patients are fully aware of their financial responsibilities we have outlined our patient financial policy below
- Treatment must be paid for at the time of my appointment. Accepted terms of payment are cash, EFTPOS, or cheque - We do not accept American Express
- Riverina Orthopaedics is not a bulk billing practice and I am ultimately responsible for the payment of my treatment
- No Medicare rebate can be processed unless a valid referral has been provided by my general practitioner or specialist
- If my treatment is covered by a 'WorkCover Injury' or a 'Compulsory Third-Party Claim' then the following conditions apply
  - Until Riverina Orthopaedics is provided with Insurer claim details, I am responsible for all treatment expenses
  - If the claim is closed or declined, then I am liable for ongoing treatment costs and/or any appointments following the date of the claim closing
- If involved in a legal dispute, payment is due when services are rendered, regardless of any pending legal decisions
- Purchasing products from Riverina Orthopaedics, due to the nature of that product, I cannot return it later seeking exchange or refund
- I am aware it is my responsibility to confirm with my private health fund all treatment prior to proceeding with surgery
- I understand failure to settle any financial accounts in full by the desired date then the account will be referred to a collection agency and/or law firm. As part of that referral I will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs
- For DVA patients only - I am aware that as a Department of Veteran Affairs (DVA) patient (white or gold card), I am liable for costs associated with products purchased from Riverina Orthopaedics, e.g. camboot, wrist splint etc. Riverina Orthopaedics will provide me a letter clinically justifying the purchase so I can seek reimbursement from DVA
I have read "Health Information Collection and How We Use It". I understand and give consent to my information being used as outlined above*

YesNo
I have read the "Financial Terms and Conditions" and understand my responsibilities*

YesNo
By typing your name you agree that the information you have provided is true and correct*

First NameLast Name
Date of completion*
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