Patient Registration. Thank you for choosing GenesisCare, Australia s largest provider of radiation oncology services.

Transcription

1 Patient Registration Thank you for choosing GenesisCare, Australia s largest provider of radiation oncology services. To assist us in providing you with optimal care we ask that you read the information contained within this pack and complete the registration forms before your first radiation therapy consultation appointment. The enclosed papers include our privacy policy, an outline of your rights and responsibilites, our contact details and patient registration forms. If you require assistance, please contact our Patient Services Team at your treating centre.

2 1. Demographics Title First Name (as per Medicare Card) Initial Surname Preferred Name Phone Street Address Work Mobile Postal Address (eg. PO Box) Suburb State Postcode Date of Birth / / 2. Radiation Treatment Time Preferences Please indicate your radiation treatment appointment time preference If you proceed to treatment we offer morning or afternoon treatment sessions. You will receive your weekly treatment schedule each Friday. Our bookings team will endeavour to accommodate your time preferences, however, this may not be possible for certain treatment techniques such as stereotactic radiation therapy, or for at least the first 2 weeks of your treatment due to time slots already filled by existing patients. If you have special circumstances such as community transport time restrictions, please speak with our patient services team. 3. Patient Details Please tick Gender Male l Female l Interpreter required Yes l No l Country of Birth Language spoken at home below: l AM l PM l I am flexible with treatment times Special Circumstances: If you require an interpreter, please notify the Patient Services team, they will ensure one is available for your appointment. Please note carers or staff members cannot be used when discussing clinical information. 4. Are you of Aboriginal or Torres Strait Islander heritage? Please tick No l Yes, Aboriginal l Yes, Torres Strait Islander l Yes, both Aboriginal and Torres Strait Islander l 5. Patient checklist - please fill in your card numbers where possible below and bring these (and ALL other applicable cards) to your first appointment l Specialist and/or GP Letter l Concession Card Concession Card No. Health Concession Card No. Completed Registration Pack l l Health Concession Card i.e. this booklet - if not completed online l Private Health Fund Card l Pension Concession Card Pension Concession Card No. l Department of Veterans Affairs Card l Ambulance Membership No. Ambulance Membership No. Device Card l (applicable for patients with a cardiac implanted device) l Medicare Card Medicare Card No. l Power of Attorney documentation (if applicable) Ref No. Expiry Page 2

3 6. Next of Kin Contact Alternative Contact (who doesn t live with you) (We may contact these people in case of an emergency, for appointment or account information). Next of Kin Name Alternative Contact Name Street Address Street Address Relationship Next of Kin Phone Relationship Alternative Contact Phone 7. Medical Contacts Your Referring Specialists Name Specialist Phone No. Specialist Address Suburb State Postcode Your General Practitioners Name GP Phone No. GP Address Suburb State Postcode Other doctors involved Phone No. Drs Address Suburb State Postcode 8. Do you have any implanted devices? Yes l No l If yes, type of implanted device: If pacemaker, Cardiologist name: Phone: Page 3

4 Medications List Affix Patient Label Please complete the following table to the best of your knowledge if you take medication/s. This will assist us with our screening processes to ensure we keep you safe. MEDICATION DOSAGE FREQUENCY (if known) MEDICATION ALLERGIES REACTION SEVERITY Page 4

5 Affix Patient Label Privacy Consent Form To enable the ongoing provision of care and total quality improvement within this practice, and in keeping with the Privacy Act 1988 (Cth) and Australian Privacy Principles (APPs), we wish to provide you with information on how your personal and health information may be used or disclosed and record your consent or restriction to this consent. Your personal and health information will only be used for the purposes for which it is collected, or as otherwise permitted by law. GenesisCare collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. Collection We will seek to collect the following information: Full medical history; Family medical history; Contact details; Medicare/private health fund details; Billing/account details; and/or Details of all medical consultations, treatments and tests performed. This information will normally be collected directly from you. There may be occasions when we will need to obtain information from other sources that may include: Other medical practitioners such as current and former GPs & specialists; and/or Other health care providers such as physiotherapists, occupational therapists, psychologists, pharmacists, dentists, nurses, hospital & day surgery units. Our practice staff & doctors may participate in the collection of this information. In emergency situations we may need to collect personal information from relatives and/or other sources where we are unable to obtain your prior consent. Use & Disclosure With your consent your information will be used in the following ways: Providing our health care services and other services; Administrative purposes for running our medical practice, including maintaining and updating our records and training our people; Exchanging information between GenesisCare Group entities; Communicating with other specialists, general practitioners / referring doctors, and health service providers such as pathologists, radiologists, allied health professionals, pharmacists, in relation to the relevant individual s diagnostic service or treatment; Quality assurance, practice accreditation and licensing, management, funding, service-monitoring, complaint handling, planning, evaluation and audit activities; To comply with statutory and public health reporting requirements, such as mandatory reporting of child abuse or the notification of diagnosis of certain communicable diseases; Communicating with medical defence organisations, insurers, medical experts or lawyers for medical indemnity purposes and anticipated or existing legal proceedings; Disclosure to an individual s close relatives, close friends, and personal representatives, unless directed otherwise by the individual; Disclosure to an individual s lawyers and insurance companies that have been authorised by the individual to obtain personal information from us; Page 5

6 Affix Patient Label Privacy Consent Form Continued Conducting patient surveys (e.g. for the purpose of improving services) For research & development projects which may include undertaking research feasibility, benchmarking, clinical indicator reporting, guideline adherence & treatment evaluation/compliance. GC may enter into commercial relationships with external entities using de-identified, aggregated data ensuring that it cannot be used to identify an individual Billing, payment processing and debt recovery; Processing of clinical transcription files; Reviewing the accuracy, upgrading and testing of patient medical record systems; Where we engage service providers, such as providers of archival, auditing, accounting, legal, banking, payment, debt collection, delivery, data processing, document management, research, investigation, insurance, website or technology services (including, for example, via cloud based storage providers which may be located outside Australia); Protecting our lawful interests; In response to orders of a court or tribunal, such as producing records in relation to court proceedings; and Purposes consented to by the individual. Accessing Your Medical Records You are entitled to access your health records at any time convenient to both yourself and the practice. Access may be denied in some situations: To provide access would create a serious threat to life or health; Where there is a legal impediment to access; Where access would unreasonably impact on the privacy of another; and/or If the information relates to anticipated or actual legal proceedings and you would not be entitled to access the information in those proceedings. Where possible, your request for access should be made in writing. Where you dispute the accuracy of the information recorded you are entitled to seek to correct that information. While any corrections will be recorded in your file, the original record will not be erased. Consent I have read the information above and understand the reasons why my information must be collected. I am also aware that the GenesisCare Group has a privacy policy on handling patient information which is displayed on its website. I consent to the handling of my information by GenesisCare for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice which shall be included in this form. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I am aware of my right to access the information collected about me, except in some circumstances where access might be legitimately withheld. I understand I will be given an explanation in these circumstances. SMS or messages may be sent to your designated mobile number. SMS messages will be sent to you informing you of delays where these occur if you prefer not to receive an SMS notification please inform one of our friendly Patient Services Team who are found at our reception counters. Patient s name (please print) Signed Date / / Receive SMS messaging YES l NO l Page 6

7 Rights and Responsibilities Patient Registration asks you to confirm that you have been informed about your rights and responsibilities while attending a GenesisCare facility. The following summarises our mutual responsibilities so that we can work together to provide you with the best possible care. Description of your rights As a patient receiving treatment at GenesisCare, you have the right to: Receive safe, high quality treatment and care; Treatment with respect, dignity and consideration; Take part in making decisions about your treatment and care; Be provided with information about our service fees and payment options; Privacy and confidentiality of your personal information; Access to information about your health care; Ask to see your medical record; Information on the steps the organisation takes to improve the quality of care; Comment on your care and have your concerns addressed; The right to have an interpreter if required. You have the responsibility to: Keep your referrals up to date whilst visiting our centre; Description of your responsibilities Provide our staff with as much relevant information about your health as you can; Tell staff about any medications that you may be taking; Not display offensive, aggressive or intimidating behavior to any staff member, other patients or their carers; Arrange an interpreter if required; Respect the confidentiality and privacy of others. Page 7

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9 GenesisCare Victoria Radiation Oncology Centre locations Albury Wodonga c/- Albury Wodonga Regional Cancer Centre Corner Borella Rd and East St East Albury NSW 2640 Tel: (02) Fax: (02) Berwick c/- Casey Specialist Centre 55 Kangan Drive Berwick VIC 3806 Tel: (03) Fax: (03) Cabrini c/- Cabrini Hospital Malvern 183 Wattletree Road Malvern VIC 3144 Tel: (03) Fax: (03) Medical & Specialist Centre GF, 230 Cooper St VIC 3076 Tel: (03) Fax: (03) Footscray c/- Western Private Hospital Cnr Eleanor & Marion Sts Footscray VIC 3011 Tel: (03) Fax: (03) Frankston c/- Frankston Private Frankston-Flinders Rd Frankston VIC 3199 Tel: (03) Fax: (03) Western Freeway Footscray Footscray Fitzroy Footscray Footscray Prin ces Highway Calder Freeway Western Freeway Prin ces Highway Calder Freeway West Ring Rd freeway freeway Westgate Westgate Ringwood Ringwood East East c/- Ringwood c/- Ringwood Private Hospital Private Hospital 36 Mt. Dandenong 36 Mt. Dandenong Rd Rd Ringwood Ringwood East VIC East 3135 VIC 3135 Tel: (03) Tel: 8870 (03) Fax: (03) Fax: 8870 (03) St Vincent s St Vincent s Hospital Hospital Basement Basement Level Building Level Building C C 41 Victoria 41 Victoria Parade Parade Fitzroy VIC Fitzroy 3065 VIC 3065 Tel: (03) Tel: 9427 (03) Fax: (03) Fax: 9427 (03) West Ring Rd Cit ylink Port Port Phillip Phillip Bay Bay Fitzroy HUME HYW Hume Freeway Citylink SCHUBACH ST Ring Ring Rd Rd Metropolitan Metropolitan Cit ylink St Vincent s St Vincent s Cabrini Cabrini HUME HYW Hume Freeway Citylink SCHUBACH ST Malvern E E astern astern Freewa Freewa y y Malvern Frankston Frankston RIVERINA HWY ELECTRA ST Monash Freeway Eastlink Frankston Frankston RIVERINA HWY ELECTRA ST SMITHWICK LN SMITHWICK LN GenesisCare GenesisCare Radiation Oncology Radiation Centre Oncology Centre Albury WodongaAlbury Wodonga Eastlink KEENE ST 10 km Ringwood Ringwood Ringwood Ringwood Monash Freeway KEENE ST 10 km Eastlink Eastlink Berwick Berwic N BORELLA RD Albury Wodonga Regional Cancer Centre Berwick AIRPORT N BORELLA RD B A Albury Wodon Regional Canc Centre EAST ST ROV-FRM-119