Perth Women's Specialist Clinic - Patient Information

Patient Information Form

Your Details

Name must match Medicare card's name

Title

Given Name

Last Name

Street Address

Suburb

Postcode

DOB

Height

Weight

Marital Status

Current Occupation

Contact Details

Contact Phone No.

Work Phone No.

Mobile No.

E-mail Address

Emergency Contact Details/ Next of Kin (NOK)

Partner's Name

Partner's Contact No.

NOK's Name/ Relationship

NOK's Contact No.

Your GP

Referring Doctor

Your Usual GP's Name and Address (if different to above)

Medical Insurance

Medicare Number

Medicare Reference No. (alongside your name)

Medicare Expiry Date

Private Health Fund Name

Uninsured

Private Health Fund Membership Number

Medical Issues

Medical History (please list any medical problems you have)

Surgical History (please list any surgeries you have had in the past)

Obstetric History (please list any pregnancies including miscarriages, terminations to date in order); please include details of the pregnancy, i.e. the year, outcome of pregnancy, complications etc.

The result & year of last PAP smear/ HPV cervical screening test

Medications

Allergies

Smoking

YES NO

Alcohol

YES NO

Family History (please list any medical problems that run in the family)

How did you hear about Perth Women's Specialist Clinic

Consent To Use Of Digital Note Taking

For the purpose of documentation and to ensure accurate record-keeping, your consultation may be recorded and transcribed in real time using a digital note taking tool. Our clinic uses I-scribe and Medow AI. These recordings are temporary and are deleted once the required information has been captured. Only your clinician has access to your medical information.

I-scribe and Medow AI i complies with the Australian Privacy Principles and the Privacy Act. Its systems are accredited for data security. All data is encrypted, securely and confidentially stored on servers located within Australia to meet local legal requirements.

I-scribe and Medow AI will not be used without your consent. You can withdraw your consent at any time. To find out more please visit https://i-scribe.com.au and https://www.medowhealth.ai

I consent to the use of digital note taking:

YES NO

Consent To Assignment of Medicare Benefit

I understand that this practice is not a bulk-billing practice. Consultation and procedure fees are payable in accordance with the practice fee schedule. I understand that where my practitioner elects to bulk bill a Medicare service, I will be asked to assign my Medicare benefit to the practitioner for that specific service.

I authorise this practice to submit Medicare claims on my behalf and to receive, use and disclose information necessary for the purpose of processing Medicare claims and rebates.

Where a service is bulk billed, I assign my right to the Medicare benefit to the treating practitioner and authorise payment of the Medicare benefit directly to the practitioner. I understand that no separate Medicare benefit is payable to me for that service.

For "NO GAP fee" in hospital treatment, I agree to assign my right to the Medicare benefit to the treating practitioner or my private health insurance. This assignment enables patients to allow their private health insurer to receive and manage Medicare benefits on the behalf along with their private health insurance benefit.

The process for privately insured patients to assign their Medicare benefit is being modernised to help strengthen Medicare, reduce administrative burden and streamline simplified billing processes.

Should I not consent to the above, I agree to pay the total fee and claim Medicare and private health rebates myself.

I consent to Assignment of Medicare Benefit

YES NO

Signature

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Draw your signature using your mouse, finger or stylus.

Please provide & complete the following :

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Privacy & Consent

The information we collect is used for the primary purpose of providing quality health care and may be utilized in the following ways:

Administrative purposes connected to the running of our medical practice.
Billing purposes, including compliance with Medicare and the Health Insurance Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

By submitting this form, I agree that:

I understand the reasons why my information must be collected.
I understand that I am not obliged to provide any information requested, but that failure to do so might compromise the quality of the health care and treatment given to me.
I am aware of my rights to access the information collected about me, except in some circumstances where access might legitimately be withheld and that an explanation will be given in this circumstance.
I understand that if my information is to be used for any purpose other than the above, my further consent will be obtained.
I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.