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Medical Consent and Exchange of Health Information Form

I (Client/Carer) Consent to engage voluntarily with Melbourne Aged Care Pty Ltd ("MAC") for the purpose of providing:

education/care/treatment for care coordination and/or physiotherapy services.

I consent to my health information being

being exchanged between services**

being shared with family*

being shared with informal support staff who are providing my care*

* Health information includes but is not limited to personal information that is or about; - An individual's physical, mental or psychological health or an individual's disability - An individuals expressed wishes about the future provision of health services to him or her - A health service provided. or to be provided, to an individual ** Services include although are not limited to:

-Aids and Equipment Programs -Post Acute Care Services -Community Services -Carer Support Services + Other (please specify)

Other services to be provided (if any):

- Local doctors - Treating Hospitals - My Aged Care Facility - Case Managers.

Consent and Acceptance

The Information collected will be in accordance with ‘The Privacy Act’ (1988) which I have read or had explained to me. All of the above has been explained in a language that I understand.

Full Name of Patient

Date

Phone

Email copy to

Signature of Patient

Sign Here - use your finger to sign

Upload Photo of Medicare card (if possible)

Size limit: 10 MB

Office Use Only

I have discussed with the client their consent –

I am satisfied the client / carer understands and has provided their informed consent to these.

Medical Consent and Exchange of Health Information Form

I consent to my health information being

Consent and Acceptance

Full Name of Patient

Date

Phone

Email copy to

Upload Photo of Medicare card (if possible)

*Office Use Only*

Provider Name (on behalf of MAC)

Date

Signature

Office Use Only