New Patient Information Online Form

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Contact and Personal Information

First Name*

Middle Name

Last Name*

Known As

Title*

Mrs

Miss

Date of Birth*

Address*

Street Address Suburb City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Mobile*

Email*

Height (cm)

Weight (kg)

Medicare and Other Health Insurance Details

Medicare No*

Card Ref*

Expiry*

Health fund*

Membership No*

Do you have Hospital Cover?

Yes

Have you been in the fund longer than 12 months?*

Yes

Name of the person responsible for this account if different to the above

GP Details

GP Name*

Practice Name*

GP Address

Emergency Contact Details

Emergency Contact Name*

Relationship to Patient*

Emergency Contact Phone*

Patient Information

FEES:

This is a PRIVATE BILLING Practice and the Fees are charged based on AMA recommendations.

Initial and Subsequent Consultation costs are provided in an email that is sent when an appointment is made.
All patients will be provided with a written Quote for any proposed surgery that they may require.

Payment in FULL is REQUIRED ON the DAY of your Consultation. We can submit your A/C to Medicare on your behalf. The Item numbers and Costs may vary depending on your Examination at the time of the Consult

Failure to attended an Appointment without having cancelled it with the Rooms at least 24 hours prior, may attract a fee which is not claimable through Medicare.

PATHOLOGY:

If you have a Colposcopy, Biopsy or any other Pathology carried out at your Consultation, you will receive a separate Pathology A/C via the mail. This will be partly claimable through Medicare.

REFERRAL LETTER:

We will require a CURRENT REFERRAL LETTER from your GP or Specialist prior to your Appointment.

From your GP – this will last "12 months" from the date given
From your GP – You can ask them for "Indefinite" Referral
From a Specialist – this will only last "3 months" from the date given

PRIVACY INFORMATION SHEET

Introduction:

We are committed to protecting the privacy of patient information and to handling your personal Information in a responsible manner in accordance with the Privacy Act 1988 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy Principles and relevant State and Territory privacy legislation (referred to as privacy legislation).

This Privacy Information Sheet explains how we collect, use and disclose your personal information, how you may access that information and how you may seek the correction of any information. It also explains how you may make a complaint about a breach of privacy legislation.

This Privacy Policy is current as at 01/02/2020. From time to time we may make changes to our Policy, processes and systems in relation to how we handle your personal information. We will update this Privacy Policy to reflect any changes. Those changes will be available on our Website www.rajmohan.com.au and in the Practice.

Collection:

We collect information that is necessary and relevant to provide you with medical care and treatment, and manage our medical Practice. This information may include your name, address, date of birth, gender, health information, family history, credit card and direct debit details and contact details. This information may be stored on our computer medical records system.
Wherever practicable we will only collect information from you personally. However, we may also need to collect information from other sources such as treating Specialists, Radiologists, Pathologists, Hospitals and other health care providers.
We collect information in various ways, such as over the phone or in writing, in person by our Practice Staff or over the internet if you transact with us online. This information may be collected by medical and non-medical staff.
In emergency situations we may also need to collect information from your relatives or friends.
We may be required by Law to retain medical records for certain periods of time depending on your age at the time we provide services.

Use and Disclosure:

We will treat your personal information as strictly “Private and Confidential”. We will only use or disclose it for purposes directly related to your care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment. For example, the disclosure of blood test results and correspondence to your Specialist / GP or requests for x-rays.

There are circumstances where we may be permitted or required by Law to disclose your personal information to third parties. For example, to Medicare, Police, Insurers, Solicitors, Government Regulatory bodies, Tribunals, Courts of Law, Hospitals, or Debt Collection Agents. We may also from time to time provide statistical data to third parties for Research purposes. We may disclose information about you to outside contractors to carry out activities on our behalf, such as an IT service provider, Solicitor or Debt Collection Agent. We impose security and confidentiality requirements on how they handle your personal information. Outside contractors are required not to use information about you for any purpose except for those activities we have asked them to perform.

Data Quality and Security:

We will take reasonable steps to ensure that your personal information is accurate, complete, up to date and relevant. For this purpose, our staff may ask you to confirm that your contact details are correct when you attend a consultation. We request that you let us know if any of the information we hold about you is incorrect or out of date.

Personal information that we hold is protected by:

Securing our premises;
Placing passwords and varying access levels on databases to limit access and protect electronic information from unauthorised interference, access, modification and disclosure; and
Providing locked cabinets and rooms for the storage of physical records.

Corrections:

If you believe that the information we have about you is not accurate, complete or up-to-date, we ask that you contact us in writing as per the above address.

Access:

You are entitled to request access to your Medical Records. We request that you put your request in writing and we will respond to it within a reasonable time.

There may be a fee for the administrative costs of retrieving and providing you with copies of your Medical Records.

We may deny access to your Medical Records in certain circumstances permitted by Law, for example, if disclosure may cause a serious threat to your health or safety. We will always tell you why access is denied and the options you have to respond to our decision.

Complaints:

If you have a complaint about the privacy of your personal information, we request that you contact us in writing. Upon receipt of a complaint we will consider the details and attempt to resolve it in accordance with our complaints handling procedures.

For any queries or complaints please direct to: Kell Muir (Practice Manager) A/Prof Raj Mohan kell@rajmohan.com.au

If you are dissatisfied with our handling of a complaint or the outcome you may make an application to the Australian Information Commissioner or the Privacy Commissioner in WA (Western Australia).

Overseas Transfer of Data:

We will not transfer your personal information to an overseas recipient unless we have your consent or we are required to do so by law.

Pathology / Bloods / Radiology Results:

All Results once to hand will be viewed by A/Prof Mohan. A/Prof Mohan or his Nurse will then call you with these results.

OH&S Guidelines:

Our Facility and Services endeavour to meet Occupational Health and Safety Guidelines for the health and safety of our patients attending our Practice.

Our Bariatric chairs have a maximum weight limit of 272 kgs.
Our Standard chairs have a maximum weight limit of 120 kgs.
The Examination bed has a maximum weight limit of 200 kgs.

Should you be outside of this weight allowance, please beware our Practice takes no responsibility for personal accident or injury.

Contact:

Please direct any requests in writing for access to Medical Records to:
(Secretary) A/Prof Raj Mohan info@rajmohan.com.au

GYNAE ONCOLOGY WA

New Patient Information Online Form

Contact and Personal Information

Medicare and Other Health Insurance Details

GP Details

Emergency Contact Details

Patient Information

PRIVACY INFORMATION SHEET

Medical History Form

MEDICAL HISTORY

	148A Cambridge Street, (Cnr St Leonard’s Avenue), West Leederville, WA 6007 FREE PARKING ONSITE
	info@rajmohan.com.au
	(08) 9388 8141
	(08) 9388 8934

Monday - Thursday	9am - 5pm With the phone answered to 4pm daily
Friday	8am - 1pm
The Practice will be closed on a	Monthly Friday
Weekends and Public Holidays	Closed

Contact and Personal Information

Medicare and Other Health Insurance Details

GP Details

Emergency Contact Details

Patient Information

PRIVACY INFORMATION SHEET

**Medical History Form **

MEDICAL HISTORY

Medical History Form