New Patient Registration

Personal Contact Details

Emergency Contact Details (Next of Kin)

Other Information

Medicare

Medicare

Private Health Fund

Veteran Affairs

Workcover

TAC/ MAIB

Collaborative Care Information

Please list names and details of all other practitioners who are involved in your medical care.

This includes specialists and allied health care professionals.

Your Medical Information

Current Medications

Please list all your current medications and doses in detail.

Allergy Information

Patient Consent

MEDICAL INFORMATION:

Persistent Pain solutions will maintain medical records containing your personal details. These details will include:

• Name
• Address
• Date of Birth
• Details of your referring doctor
• Other health fund or third-party details (e.g.: Workcover, TAC)

Other information of clinical relevance will be held by Persistent Pain Solutions during the period of management and will be maintained in a scanned (secure digital record) or paper based confidential file management system for up to seven years.

Your information may be shared with other health practitioners involved in your treatment if necessary. In some circumstances, a legal obligation to disclose clinical information may arise.

My consent will apply to this and any subsequent consultations. I understand that I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.

• Collect personal information and my medical history from various sources to address my medical requirements accurately and completely. This will assist in optimisation of my medical condition. The information may be collected by several different methods such as medical test results, notes from consultations, Medicare details, data collected from observations and conversations, and details obtained from other health providers (e.g., specialist correspondence).
• Use or disclose my personal and medical information for the following purposes:
  • Administrative purposes in the operation of the practice.
  • Billing purposes, including compliance with Medicare requirements.
  • For legal related disclosure as required by a Court of Law.
  • To comply with any legislative or regulatory requirements, e.g. notifiable diseases.
• Communicate or discuss relevant medical information about me with my referring doctor and any healthcare provider to whom I am referred to.
• Communicate or discuss relevant medical information with my insurance or legal representatives (for e.g., insurer, employer, solicitor) or a third party such as Workers’ Compensation, DVA or TAC.
• Incorporate information regarding my medical management on my printed receipt to facilitate claiming medical rebate and entitlements.
• Request relevant medical information regarding my medical history from other doctors or health care providers involved in my management.
• Contact me to recall for follow up of medical problems as deemed necessary. (via SMS, email or mobile)
• Send my medical information to me on my request via mail or email. I understand that this is not a secure mode of medical communication.
• Disclose pertinent de-identified medical information for research, presentations and quality assurance activities to facilitate improvement of individual and community health management.

GUARDIANS:

This document is to be read as from the perspective of the patient for whom you are a guardian.

A fee will be charged for all consultations and medical procedures. Persistent Pain Solutions is not a Bulk Billing Practice. You will be informed of the fee payment schedule by Persistent Pain Solutions at the time of the appointment booking. Full payment is respectfully requested at the time of consultation. Pre-payment will be requested for all telehealth appointments and interventional procedures. Medicare/ Private Health Fund will reimburse a portion of the doctor’s fees.

You will be provided with written financial information and quote if interventional procedures are suggested which must be signed and returned before a procedure is booked.

• The Fee payment schedule at Persistent Pain Solutions.
• Medicare/ Private Health Fund may not cover the total amount invoiced by Persistent Pain Solutions.
• Prepayment will be required for all telehealth consultations and interventional procedures.
• That payment of the account is my responsibility. I am responsible for any further costs that may be incurred because of not paying the account in full, by the due date.
• That it is my responsibility to ensure I have an updated referral from my referring doctor for any appointment attended at Persistent Pain Solutions.
• In the event my Work Cover or TAC claim becomes inactive, I acknowledge that I will be responsible for payment of any outstanding invoices.
• That it is my responsibility to ensure that there is an updated approval for any specialist appointments at Persistent Pain Solutions.

CONSENT:

I have read the information in the above patient consent form and understand the contents in its entirety.