AIMHealthMelbourne Central Medical Centre Surname: First Name: Title: □ Mr □ Mrs □ Ms □ Miss □ other: Date of Birth: Gender: Address: Suburb: Post Code: State: Mobile Phone: Home Phone: Email Address: Medicare No.: Reference No.: Exp: DVA No. (Medicare client, if applicable): □ Gold □ White Concession Card (Medicare client, if applicable) □ Pension Card □ Health Care Card □ Senior HCC Card No.: Exp: If you do not have Medicare: Insurance company: □ ahm □ Allianz □ BUPA □ CBHS □ iman □ Medibank □ nib Policy No.: Type: □ OSHC □ OVHC Exp: Next of Kin Name: Phone No.: Relationship: Emergency Contact Name: Phone No.: Relationship: Do you require an interpreter service? □Yes □No To assist with health initiatives, —Are you of Aboriginal or Torres Strait Islander? □Yes □No Country of Birth: Primary Language:
Please read this consent and agreement carefully prior to signing
Part A. Patient Rights
1. I understand that I am not obligated to provide all information requested of me, but failure to do so may compromise the quality of care provided.
2. I understand that if my information is to be used for any purpose other than set out above, my further consent will be obtained.
3. I may request limitations on the access or disclosure of my health information by notifying the practice in writing.
Part B. Patient Consent
1. Collection of Information: I understand that collecting my personal and medical information is required to ensure high-quality healthcare, accurate Medicare/insurance billing, and referrals to other providers.
2. Shared Electronic Records: I acknowledge that AIM Health operates two clinic locations (AIMHealth Melbourne Student Medical Centre and AIMHealth Melbourne Central Medical Centre) that share a single electronic medical record system. I consent to my health information being accessed by authorised clinical staff at either location for the purpose of providing me with appropriate and continuous healthcare.
3. Use and Disclosure: I understand that my health information will only be used or disclosed for purposes directly related to my care, or where required or authorised by law (e.g. mandatory reporting of infectious diseases).
4. Access and Correction: I understand that I may request access to, and correction of, my health information in accordance with the Privacy Act 1988 and the Health Records Act 2001 (Vic).
5. Reminders and Follow-up: I consent to AIM Health contacting me with reminders (e.g. SMS, phone call, letter, or email) to support my healthcare. I understand that I may withdraw or amend my consent at any time by notifying the practice in writing.
6. Quality and Safety Activities: I consent to AIM Health submitting data to disease registers (e.g. cervical, breast, and bowel screening programs) and sharing de-identified information for quality improvement and clinical audit purposes.
7. Assignment of Benefits: I agree to the assignment of the Medicare benefit directly to the provider unless another arrangement is made on the day.
Part C. Practice Policies
1. Contact Details: I will inform AIM Health if there are any changes to my contact details. If I cannot be contacted, I accept responsibility for any associated consequences.
2. Appointments
• A longer appointment must be booked for multiple issues or complex health needs (e.g. TAC/WorkCover, Mental Health Care Plans, referrals to allied health, EPC referrals).
• I understand that results, prescriptions, referrals, medical certificates, MHCPs, EPCs, and other documents require an appointment.
3. Cancellations: I understand that at least one business day’s notice is required to cancel or reschedule an appointment. Failure to do so may result in a $40 cancellation fee, payable within 7 days.
4. Transfer of Records: I acknowledge that an administration fee applies for the transfer or provision of my medical records, payable upfront in accordance with Australian health record regulations.
Print Name: ___________________________
Signature:____________________________ Date: ______________________________
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