Patient Registration Form

CONSULTATION TERMS & FEES

VETERANS AFFAIRS:

Accounts will be forwarded to the Department of Veterans Affairs

WORKCOVER/TAC:

Our charges are above WorkCover and TAC schedule rates. An out-of-pocket expense will be incurred. We DO NOT bill WorkCover/TAC for consultations. Full payment is required on the day. You will be provided with a receipt for claiming with WorkCover/TAC.

If you require surgery, we will formally request approval from WorkCover/TAC and when approved, the surgery and all appointment thereafter will be forwarded to WorkCover/TAC for payment.

PAYMENT TERMS:

• Consultations: Payment is to be made at the time of consultation
• Non-attendance: if 48 hours is not given for cancellation of an appointment a $50.00 fee applies
• Surgery: Payment of the full fee/gap/out-of-pocket fee (as quoted in the Informed Financial Consent provided for surgeries) is to be made prior to surgery
• In the event an overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs
• In the event where an account is submitted to a third part, such as WorkCover/TAC, Health fund, and liability is rejected, you acknowledge that you will be liable for the full amount

By signing below, you acknowledge that you have read and understood the above and that you agree to abide by them.

TELEHEALTH CONSULTATION & FINANCIAL CONSENT

Important Information for Patients

The Spine & Orthopaedic Centre is committed to providing timely, accessible and high-quality care. While the majority of consultations are conducted face-to-face, there are occasions where a telehealth consultation may be clinically appropriate.

Telehealth consultations may be offered:

• At the request of the patient where clinically appropriate
• For urgent or unexpected follow-up after surgery or procedures
• To discuss important investigation results
• To review your progress or response to treatment
• To provide timely medical advice when an in-person consultation is not practical
• At the discretion of your treating clinician when it is considered safe and appropriate

The decision to conduct a telehealth consultation is always made by your treating doctor based on your clinical circumstances.

Why Telehealth May Be Used

Telehealth allows your treating clinician to:

• Provide timely review of your condition
• Discuss imaging, pathology and other investigation results
• Review your medications and treatment plan
• Assess your recovery following surgery or procedures
• Determine whether further investigations or an in-person assessment are required
• Coordinate your ongoing care with your general practitioner, surgeon, hospital and other healthcare providers where appropriate

Where your doctor believes that a face-to-face examination is necessary, you will instead be asked to attend the practice in person.

Financial Consent for Bulk Billing

Under current Medicare requirements, patients must provide consent before eligible telehealth services can be bulk billed.

By signing this form, you authorise the Spine & Orthopaedic Centre to submit eligible Medicare claims directly to Medicare on your behalf for clinically appropriate telehealth consultations.

Where eligible, your consultation may be billed using the appropriate Medicare Benefits Schedule (MBS) item applicable to your consultation.

By consenting to bulk billing:

• You will not incur an out-of-pocket fee for eligible bulk-billed telehealth consultations
• Medicare will pay the scheduled benefit directly to the practice
• You assign your Medicare benefit for eligible services to the practice

This consent allows us to continue providing convenient telehealth services when clinically appropriate while minimising out-of-pocket costs to our patients.

If You Do Not Consent

If you do not wish to provide consent for bulk billing:

• You may continue to receive your care through face-to-face consultations wherever appropriate
• If a telehealth consultation is requested or clinically required, it may instead be provided under the practice’s standard private fee schedule, with any applicable Medicare rebate able to be claimed by you where eligible

Providing this consent does not mean that all future consultations will occur via telehealth. Most reviews continue to be performed in person, and telehealth will only be used when your treating clinician considers it appropriate or when requested by you and deemed suitable.

Patient Consent

I acknowledge that:

• I have read and understood the above information
• I understand that telehealth consultations may occasionally be provided when clinically appropriate or at my request and approved by my treating clinician
• I consent to eligible telehealth consultations being bulk billed to Medicare where appropriate
• I authorise the Spine & Orthopaedic Centre to submit eligible Medicare claims on my behalf and accept the Medicare benefit as full payment for those eligible services
• I understand that I may choose not to provide this consent and that alternative billing arrangements may apply

PRIVACY CONSENT

Spine & Orthopaedic Centre 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 healthcare needs.

Please read this form carefully, and sign where indicated below

This means we will use the information you provide in the following ways:

• Administrative purposes in running our practice.
• Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
• Disclosure to others involved in your health care, including treating doctors, specialists and allied health practitioners outside this medical practice. This may occur through referral to other doctors, or for medical tests and in reports returned to us following the referral.
• Disclosure to other doctors or allied health practitioners within the practice for the purpose of continuity of patient care.
• For disclosure to visiting doctors and medical students attached to this practice for the purpose of patient care and teaching.
• Disclosure for the purpose of research and quality assurance activities to improve individual and community health care and practice management. Usually no individual names will be recorded but if this is not the case, you will be informed when such activities are being conducted and given the opportunity to ‘opt out’ of any involvement.
• For quality review and accreditation of the practice, medical records may need to be assessed by a visiting doctor.

I have read the information above and understand the reasons why my information must be collected. I am also aware that the Spine & Orthopaedic Centre has a privacy policy on handling patient information. I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given a reasonable explanation in these circumstances. I consent to the handling of my information by Spine & Orthopaedic Centre for the purposes set out above, subject to any limitations on access or disclosure that I notify in writing to Spine & Orthopaedic Centre. There are some circumstances where information needs to be disclosed without consent ie:

• An emergency situation
• Where disclosure is necessary to lessen or prevent a serious and imminent threat to an individual’s life, health or safety, or is a serious threat to public health or safety.
• Where disclosure is a legal requirement, eg a communicable disease, suspected abuse, subpoena to court
• For medical indemnity insurance

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 health care and treatment given to me.