Chiropractic Treatment Notification Form (Page 4 of 4) in pdf

Chiropractic Treatment Notification Form Page 4

CHIROPRACTIC TREATMENT NOTIFICATION FORM

NOTES

CONSENT INFORMATION

The treating practitioner is legally responsible for obtaining the patient’s consent for disclosure of information

where necessary.

Maintaining an open channel of communication between Agent, patient and practitioner is crucial to achieving

the best outcome possible for the patient. The treating practitioner plays a vital role in helping their patient

understand this concept.

If your patient refuses to sign this form and thus prevents the disclosure of information, difficulties may arise

regarding ongoing payment for services. This issue should be discussed with your patient. The relevant Agent

should then be notified.

COLLECTION OF PERSONAL AND HEALTH INFORMATION

Personal and health information collected on this form and in the course of providing the treatment or other

service is collected for the purposes of managing your claim, monitoring the treatment that you are receiving

and assessing your future treatment needs. It may also be used for other purposes related, or in the case of

health information, directly related, to these purposes, including for the purposes of legal proceedings arising

out of the Accident Compensation Act 1985.

Personal and health information collected about you may be disclosed to VWA; its Authorised Agent or self

insurer; to their contractors, agents and legal practitioners; to medical or legal practitioners treating or acting

for you in relation to your claim; to a court or tribunal in the course of any proceedings under the Act; and to

any person or organisation authorised by you, or by law, to obtain it.

Chiropractic Treatment Notification Form Page 4