Patient Medical History Form (Page 2 of 2) in pdf

This practice collects all of your Personal Health Information as a part of your medical record.

This information is collected so your Doctor has all of your relevant information necessary to provide you

with the medical treatment that you require. This

practice is managed under strict guidelines governed by the

Private Sector Privacy Amendment Act, enacted on the 12

of March 2014.

This information may be collected, used and disclosed for the following reasons:



For the communication of relevant information with other treating doctors, specialists, allied health

professionals, and other health care professionals



For follow up reminder and recall notices



Administratively- Accounting purposes / Medicare / Health Insurance



Quality assurance activities such as accreditation



Organisations authorised by Law to request information from the practice



For disease notification as required by law (eg: infectious diseases)

Your personal information is stored on our computer system . This information may only be accessed by authorised

persons. Unless you specifically instruct the Doctor, it will be assumed that you have given this practice permission to

disclose the information it regards as necessary, to any relevant organisations for the purpose of providing you with

the requested medical treatment.

It is important you keep the practice updated of any changes in your personal details such as addresses, and

medical details (such as medications prescribed by other practitioners), so our information we keep on yourself

is accurate.

Any information that is disposed of by this practice is done so in a secure manner. We are obliged by Law to keep all

our records for a period of seven years. Unless otherwise requested by you, the practice will keep such information

until the practice believes it is no longer relevant to do so.

Signature:

Patient/Parent/Guardian__________________________________

OFFICE USE ONLY:

REC:

Date:

____/____/_______

DR:

Patient Medical History Form Page 2