First name *
Post Code *
Date of Birth *
Do you consent to receive appointment confirmation via SMS?NoYes
Do you consent to receive payment receipts and appointment communications via email?NoYes
Private Health Fund:
DVA Card No:
DVA Card Colour:
HCC / Pension No:
Usual GP (if different from above):
Are there any other medical practitioners you would like copied on correspondence?
Emergency Contact Name:
This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:
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 that my failure to do so might compromise the quality of the health care and treatment given to me.
I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
I understand that if my information is to be used for any purpose other than the above, my consent will be sought.
I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.
I will pay for or am liable to pay the expenses for doctor’s services and these services are not excluded under the Health Insurance Act 1973 (i.e. are not for the purpose of life insurance, superannuation or provident account schemes, admission to a friendly society, health screening, mass immunisation or connected with employment) and/or Dental Benefits Act 2008.
To the best of my knowledge and belief all the information provided to Northern Beaches Neurology for the lodgement of Medicare claim is true and accurate. I authorise the medical practice to electronically transmit my claim for Medicare benefits to the Australian Government Department of Human Services on my behalf.
I also authorise the Australian Government Department of Human Services to contact the referring provider or the provider of the services if clarification of details on the account and/or receipt is required for assessment or auditing purposes. For my Medicare claim, I consent to this practice sending to, and receiving from the Australian Government Department of Human Services, the following information for verification:
Privacy Notice: Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim.
The Medicare Benefit will be paid:
If your bank account details are stored with Medicare your payment will be made by EFT, if not, your Medicare benefit will not be paid.
Once you have provided Medicare with your bank account details, your payment will be released.
If required, correspondence regarding the claim will be directed to the:
ADDRESS HELD BY MEDICARE
This includes, if applicable, any Pay Doctor via Claimant (PDVC) cheques for the service provider. It is the responsibility of the claimant to forward the PDVC cheque to the service provider or to bring it to Medicare office for further enquiry.
I have read, understood and accepted all of the above information. I will notify the practice at the time of payment if I choose to submit my own Medicare claim.