New Patients

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Gender
Do you require an Interpreter?
Medicare / Health Insurance Details
Type
Hospital cover
Emergency Contact

I,

consent for the Cardiovascular Centre to contact and provide any information to the below nominated person if required in the case of an emergency or if I am not contactable:

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Authorisation to store and release patient information

Information that you provide will be documented and stored as part of your ongoing care. All precautions will be taken to maintain these records securely. It will be available to your treating physicians and their staff.

A summary of your care will be provided to your referring doctor. Copies of these summaries may be sent to other doctors involved in your care to ensure they are informed of your condition. Your information may be released to other health care providers if deemed to be in your best interest. Occasionally, we are obliged by law to release details.

Cardiovascular Centre Privacy Policy is available at https://www.cardiovascularcentre.com.au/about/privacy-policy/

Signed consent

I consent to the handling of my information by this practice for the purposes and manner set out above, subject to any specific limitations on access or disclosure that I will notify in writing.

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Account payment responsibility

The Cardiovascular Centre is a private billing practice and fees are payable at the time of consultation. It is practice policy that all accounts are settled in full on the day of your consultation.

Our fees are set by the doctors in the practice and patients should be aware that individual doctors may bill at different rates. Our doctors generally do not bulk bill for consultations or investigations, thus an out-of-pocket expense should be expected. The overall cost of your care at the Cardiovascular Centre will vary depending on the number and length of your consultations and the investigations you require. We recommend you discuss what fees you might expect with the reception staff PRIOR to your appointment, as the cost of your care may vary between visits.

We encourage our patients to register their bank account details with Medicare to allow for prompt reimbursement of the Medicare rebate to the nominated bank account. Patients can register online at www.humanservices.gov.au/online or download a Medicare Bank Account details form.

No Referral Policy

If you present to your appointment without a valid referral you are liable for the full fee on the day of the visit. Medicare will not provide a rebate with no valid referral. Please ask our reception staff any questions you have about our fee policy.

Patient Agreement

I have read the information about fees above and have no further questions about the Cardiovascular Centre’s fee policy. I understand that full payment is expected on the day of my appointment. I accept full responsibility for the fees associated with my care.

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Patient signature
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Authority to obtain medical information

I,

authorise the release of my health information as requested to the Cardiovascular Centre.

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Patient signature
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Advanced Care Directives
Do you have an Advance Care Directive or other order in place?
Authority to Release Medical Information via Email

I authorise the Cardiovascular Centre to release my medical information via electronic mail (email) to my email and/or the email of my family member/carer detailed above, and as necessary, any health practitioner involved in my treatment.


I am aware that the Cardiovascular Centre does not have encrypted email software and cannot guarantee that information transmitted via email will not be intercepted by other parties. By signing this form, I agree to not hold the Cardiovascular Centre or its employees responsible for any breach of confidentiality that may occur by someone else accessing the information contained in any emails sent to or from the Cardiovascular Centre regarding my personal health information.


I understand that reasonable means will be used to protect the security and confidentiality of the email. All concerns to and from me regarding my personal health information will be a part of my medical record and can be viewed by Cardiovascular Centre doctors and support staff. My email will not be forwarded outside the office without my consent or as required by law.


This release may be revoked at any time by written notice and is valid until such revocation is received by the Cardiovascular Centre.

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