PATIENT CONSENT & PRIVACY IS THE CONCERN OF OUR PRACTICE
The doctors at Kingston Family Clinic aim to provide patients with high quality continuing care combined with respect for your privacy. Our practice requires a confidentiality statement from doctors, allied health professionals, nursing and administrative staff.
We comply with privacy legislation and maintain patient confidentiality. We need your consent to collect personal information about you. It is important to explain who we may disclose this to, how this would happen and why.
Typical situations are:
- The diagnosis and treatment of your problem including communication with practice staff, specialists and other health care providers involved in treating you.
- Preventative medicine
- Our practice administration, accreditation and quality assurance.
- Billing and collection of professional fees
- Teaching, medical studies and research (any release of information for non-professional purposes does not contain patient identification). If you do not want your records accessed for this purpose we will note your records accordingly.
- Our “patient recall” system
- Emergency and after hours contact, and change of appointment times.
- Disclosure to others for medico legal purposes if necessary.
You may nominate any person/s you are comfortable for us to release information on your behalf such as prescriptions, test results, specialist appointments and referrals.
I have read this form and understand why collecting information about me is necessary. I consent to the handling of my information by this practice for the purpose set out above.
Full Name ______________________________________ Date of birth ____/____/______
Signature ______________________________________ Date _____/____/20
Please feel free to talk to your doctor or me should you need any clarification.
Jill Dewey
Practice Manager