Participant Consent Form
Consent for Personal Information, Media Usage, Third-Party Release, and NDIS Audit Participation.
Participant Details
| First Name: | Last Name: | ||
| NDIS Number: | Date of Birth: | DD / MM / YYYY | |
| Phone Number: | Mobile Number: | ||
| Email Address: | |||
Personal Information
Personal information collection, holding, use and disclosure of personal information by Holistic Healthcare Management Services is protected by the Privacy Act 1988 (Cth), Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and any relevant state or territory legislation and regulations.
Personal information is any information or an opinion that identifies you or could identify you and includes information about your health.
The purpose of collecting personal information from you is to:
- Providing our services, which may include, but are not limited to, planning, coordinating, implementing, monitoring and reviewing the services to be provided to you.
- Report to the NDIS Commission or other funding bodies on how funding is serviced by us.
- Take photographs and videos for therapeutic and/or marketing purposes.
- Responding to your feedback and complaints, and
- Responding to your queries.
Holistic Healthcare Management Services will not disclose/use information about you for any secondary purpose unless:
- You have consented to the use or disclosure; or
- You would reasonably expect us to use or disclose the information for the secondary purpose as it is directly related to the primary purpose; or
- The use or disclosure of the information is required or authorised by or under an Australian law or a court/tribunal order; or
- Holistic Healthcare Management Services reasonably believes the use or disclosure is necessary to lessen or prevent a serious threat to the life, health or safety of an individual or to public health and safety; or
- Holistic Healthcare Management Services has reason to suspect an individual may have done something unlawful or engaged in serious misconduct that relates to Holistic Healthcare Management Services’s functions or activities;
- Holistic Healthcare Management Services reasonably believes that the use or disclosure is reasonably necessary to assist another person in locating a person reported as missing.
I, __________________________________________________, hereby authorise Holistic Healthcare Management Services to collect, store, use, and disclose my personal and sensitive information, including health records, for the primary purpose of providing services and addressing related needs. This authorisation is granted in accordance with the Privacy Act 1988 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth), and any relevant state or territory legislation and regulations. This authorisation remains valid for the duration of my participation with Holistic Healthcare Management Services
| Participant’s Name: | Signature: | Date: | |||
| Representative’s Name: | Relationship to Participant: | Signature / Date: |
Use of Media
Please tick if you authorise us.
- ☐ I give Holistic Healthcare Management Services authorisation to take and use photographs and videos of me for therapeutic purposes (if applicable)
- ☐ I give Holistic Healthcare Management Services authorisation to take and use photographs and videos of me for marketing purposes.
- ☐ I give Holistic Healthcare Management Services authorisation to send me information about services via a Newsletter.
- ☐ I give Holistic Healthcare Management Services authorisation to contact me to advise me of service-related opportunities.
I __________________________________________________ give authority for Holistic Healthcare Management Services for the purpose outlined above whilst I remain a participant of Holistic Healthcare Management Services.
| Participant’s Name: | Signature: | Date: | |||
| Representative’s Name: | Relationship to Participant: | Signature / Date: |
Participant Consent for Third-Party Release of Information
| Service Type (Example: Physiotherapy) |
Name of Agency | Type of Information (Including exceptions) |
Purpose (Example: Share care) |
|---|---|---|---|
I, ____________________________________ (participant/carer/guardian), consent to information relevant to the supports/care I receive being made available as outlined below:
- ☐ I understand that the above service(s) are recommended, and relevant information about me may be forwarded to the agency(s) that provide these services.
- ☐ I understand that the service must comply with relevant privacy laws, and I will contact the organisation immediately if I feel that these laws have been breached.
- ☐ Holistic Healthcare Management Services will protect and store all my information in a locked file and will not distribute my documents other than the listed services mentioned above.
- ☐ Holistic Healthcare Management Services staff has discussed with me how and why certain information about me may need to be provided to other service providers.
- ☐ I understand that recommendation, and I give my permission for the information to be shared with the people or agencies as detailed above.
- ☐ I agree for governing bodies such as the NDIS Commission or the NDIA to access my files for audit or review of Holistic Healthcare Management Services quality indicators.
- ☐ I agree for Holistic Healthcare Management Services to collect recorded material in audio/visual format for myself or on my behalf.
I _______________________________________________________ provide consent to the release of personal information to third parties as requested by me, which is protected and governed by the privacy provisions of the Privacy Act 1988 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth), and and any relevant state or territory legislation and regulations.
If my circumstances change, I agree to notify Holistic Healthcare Management Services as soon as practicable.
| Participant’s Name: | Signature: | Date: | |||
| Representative’s Name: | Relationship to Participant: | Signature / Date: |
Note: Where a participant does not have the capacity to give informed consent and does not have a legal guardian who has the authority to make decisions on behalf of the participant, the participant’s parent, family member or another person with a close personal relationship to the participant may sign this form.
Consent to Participant in NDIS Audit
I, _____________________________________ (participant/carer/guardian), hereby provide my informed consent to participate in the NDIS audit conducted by ____________________ (NDIS Approved Quality Auditor). I understand and acknowledge that the purpose of this audit is to assess and evaluate the quality and effectiveness of the services provided to NDIS participants like myself. The audit will involve reviewing relevant documentation and conducting interviews with the participant, their carers, and relevant staff members. The information obtained during this audit will be used solely for the purposes of evaluating the services and compliance with NDIS requirements.
I understand that my participation in the audit is voluntary and that I have the right to withdraw my consent at any time without providing any reason. My decision to participate or withdraw my consent will not affect my current or future access to NDIS services or support delivered by Holistic Healthcare Management Services. Additionally, I understand that my decision to participate or not participate will be respected and will not impact the quality of the services provided to me.
I acknowledge that my personal information, including my name, address, NDIS number, and other relevant details, may be collected, used, and disclosed by Holistic Healthcare Management Services solely for the purposes of conducting the NDIS audit. I understand that the information collected during the audit will be handled in accordance with applicable privacy laws and regulations.
I agree that the findings and outcomes of the NDIS audit may be shared with relevant NDIS authorities, including the National Disability Insurance Agency (NDIA), for the purpose of compliance monitoring and improving service quality within the NDIS framework. However, my personal information will be de-identified or anonymized when shared externally to ensure my privacy and confidentiality.
I have had the opportunity to ask questions and seek clarification regarding my participation in the NDIS audit, and all my questions have been answered to my satisfaction. I have read and understood the contents of this consent form and voluntarily provide my consent for inclusion in the NDIS audit.
| Participant’s Name: | Signature: | Date: | |||
| Representative’s Name: | Relationship to Participant: | Signature / Date: |
