{"id":1723,"date":"2025-05-08T01:08:01","date_gmt":"2025-05-08T01:08:01","guid":{"rendered":"https:\/\/aimhealthmelbourne.com.au\/?page_id=1723"},"modified":"2025-05-09T15:19:07","modified_gmt":"2025-05-09T05:19:07","slug":"patient_consent","status":"publish","type":"page","link":"https:\/\/aimhealthmelbourne.com.au\/zh\/patient_consent\/","title":{"rendered":"Patient Consent"},"content":{"rendered":"<div class=\"wpcf7 no-js\" id=\"wpcf7-f1740-o1\" lang=\"en-AU\" dir=\"ltr\" data-wpcf7-id=\"1740\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/zh\/wp-json\/wp\/v2\/pages\/1723#wpcf7-f1740-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/zh\/wp-json\/wp\/v2\/pages\/1723#wpcf7-f1740-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1740\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_AU\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1740-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"uacf7-form-1740\"><p>Please read this information carefully and sign where indicated on the page.\n<p><strong>Part A. Patient Rights<\/strong>\n<p>1. I understand that I am not obligated to provide all information requested of me, but failure to do so may\ncompromise the quality of care provided.\n<p>2. I understand that if my information is to be used for any purpose other than set out above, my further\nconsent will be obtained.\n<p>3. I may request limitations on the access or disclosure of my health information by notifying the practice in\nwriting.\n<p><strong>Part B. Patient Consent<\/strong>\n<p>1. Collection of Information: I understand that collecting my personal and medical information is required to\nensure high-quality healthcare, accurate Medicare\/insurance billing, and referrals to other providers.\n<p>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.\n<p>3. Use and Disclosure: I understand that my health information will only be used or disclosed for purposes\ndirectly related to my care, or where required or authorised by law (e.g. mandatory reporting of infectious\ndiseases).\n<p>4. Access and Correction: I understand that I may request access to, and correction of, my health information\nin accordance with the Privacy Act 1988 and the Health Records Act 2001 (Vic).\n<p>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.\n<p>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.\n<p>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.\n\n<p><strong>Part C. Practice Policies<\/strong>\n<p>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.\n<p>2. Appointments\n<p>\u2022 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).\n<p>\u2022 I understand that results, prescriptions, referrals, medical certificates, MHCPs, EPCs, and other documents require an appointment.\n<p>3. Cancellations: I understand that at least one business day\u2019s notice is required to cancel or reschedule an appointment. Failure to do so may result in a $40 cancellation fee, payable within 7 days.\n<p>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.\n\n<br> <\/br>\n<strong>Patient Name<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-patient-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"your legal name\" value=\"\" type=\"text\" name=\"text-patient-name\" \/><\/span>\n<strong>Date of Birth<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"date-DOB\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" min=\"1900-01-01\" max=\"2035-05-08\" aria-required=\"true\" aria-invalid=\"false\" value=\"2000-01-01\" type=\"date\" name=\"date-DOB\" \/><\/span>\n<strong>Birth Sex<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"birth-sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"birth-sex\"><option value=\"Female\">Female<\/option><option value=\"Male\">Male<\/option><option value=\"Other\">Other<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><br>\n<strong>Gender Identity<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"Gender-Identity\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Gender-Identity\"><option value=\"Female\">Female<\/option><option value=\"Male\">Male<\/option><option value=\"Non-binary\">Non-binary<\/option><option value=\"Gender diverse\">Gender diverse<\/option><option value=\"Transgender\">Transgender<\/option><option value=\"Different identity\">Different identity<\/option><\/select><\/span><br>\n<strong>Pronouns<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"Pronouns\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Pronouns\"><option value=\"She\/Her\/Hers\">She\/Her\/Hers<\/option><option value=\"He\/Him\/His\">He\/Him\/His<\/option><option value=\"They\/Them\/Theirs\">They\/Them\/Theirs<\/option><\/select><\/span><br>\n\n<strong>Mobile Phone Number<\/strong>:<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-Mobile\"><input size=\"40\" maxlength=\"15\" minlength=\"8\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" autocomplete=\"tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"04xxxxxxxx\" value=\"\" type=\"tel\" name=\"tel-Mobile\" \/><\/span>\n<strong>\u7535\u5b50\u90ae\u7bb1<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"patient-email\" \/><\/span>\n<strong>Address Line<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-address-line\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"text-address-line\" \/><\/span>\n<strong>\u533a\uff08Surburb\uff09<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-address-suburb\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"text-address-suburb\" \/><\/span>\n<strong>Postcode<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-address-postcode\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"text-address-postcode\" \/><\/span>\n<strong>Medicare No(if applicable)<\/strong>: : <span class=\"wpcf7-form-control-wrap\" data-name=\"text-medicare-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"text-medicare-no\" \/><\/span>\n<strong>Medicare Ref No(if applicable)<\/strong>: : <span class=\"wpcf7-form-control-wrap\" data-name=\"text-medicare-ref-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\" value=\"\" type=\"text\" name=\"text-medicare-ref-no\" \/><\/span>\n<strong>Private Insurance Info(if applicable)<\/strong>: : <span class=\"wpcf7-form-control-wrap\" data-name=\"text-private-insurance\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"company name, member id\" value=\"\" type=\"text\" name=\"text-private-insurance\" \/><\/span>\n\n<strong>Emergency Contact Name<\/strong>: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-emergency-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"contact name\" value=\"\" type=\"text\" name=\"text-emergency-name\" \/><\/span>\n<strong>Emergency Phone Number<\/strong>:<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-emergency-Mobile\"><input size=\"40\" maxlength=\"15\" minlength=\"8\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" autocomplete=\"tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"04xxxxxxxx\" value=\"\" type=\"tel\" name=\"tel-emergency-Mobile\" \/><\/span>\n<strong>Signature<\/strong>:\n\t\t<span class=\"wpcf7-form-control-wrap uacf7_signature-patient\"\n\t\t\tdata-name=\"uacf7_signature-patient\">\n\t\t\t<input hidden type=\"file\" class=\"img_id_special\" pen-color=\"#000000\" bg-color=\"#eeee22\" aria-required=\"true\" aria-invalid=\"false\" name=\"uacf7_signature-patient\">\n\n\t\t\t<div class=\"signature-pad\" data-field-name=\"uacf7_signature-patient\">\n\t\t\t\t<canvas id=\"uacf7_signature-patient\"\n\t\t\t\t\tdata-field-name=\"uacf7_signature-patient\" width=\"380\"\n\t\t\t\t\theight=\"150\"><\/canvas>\n\t\t\t<\/div>\n\t\t\t<div class=\"control_div\">\n\t\t\t\t<button data-field-name=\"uacf7_signature-patient\"\n\t\t\t\t\tclass=\"clear-button\">Clear<\/button>\n\t\t\t<\/div>\n\n\t\t<\/span>\n\n\t\t\n<strong>Sign on:<\/strong>:<span class=\"wpcf7-form-control-wrap\" data-name=\"date-signed\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-signed\" \/><\/span>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"zh\"\/><\/form>\n<\/div>\n\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"class_list":["post-1723","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/pages\/1723","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/comments?post=1723"}],"version-history":[{"count":3,"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/pages\/1723\/revisions"}],"predecessor-version":[{"id":1741,"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/pages\/1723\/revisions\/1741"}],"wp:attachment":[{"href":"https:\/\/aimhealthmelbourne.com.au\/zh\/wp-json\/wp\/v2\/media?parent=1723"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}