Patient Registration - Dr Rui Niu

Name*

First Last

Date of birth

Contact details

Address

Street Address Suburb Post code

Email*

Phone

Next of Kin:

First Last

Next of Kin Phone

Next of Kin relationship to you

General practitioner / referrer:

By providing your GP’s details, we can ensure a copy of the Surgeon’s correspondence is sent to your GP.

GP's Name

Prefix First Last

Practice Name

Phone

Send findings to other interested parties /Physiotherapists :

Yes
No

Name

Prefix First Last

Practice location

Street Address Suburb Post code

Phone

Billing details

Medicare number

Expiry

Health fund name

Health fund number

Work cover insurer

Claim number

Privacy Information Consent and Declaration 

We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below.

The Practice collects information from you so we can assess, diagnose and treat your illnesses properly and be pro-active in your health care. We will use your information in the following ways in accordance with the Privacy Act 1981 and with the Australian Privacy Principles (APPs)

Administrative purposes in running this medical practice.
Billing, including compliance with Medicare and health insurance company requirements.
Disclosure to others involved in your health care, including treating doctors, specialists and physiotherapists outside this medical practice who are, or may become involved in treating you. This may occur through referrals to other doctors, or for medical tests and in the reports or results returned to us following the referrals.
Patient information shall not be released to a third party without the express consent of the patient. Please let us know if you do not want your records accessed by particular entities and we will note your record accordingly.

I have read the information above and 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. 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 about which I notify this Practice now or at any future time. I am also aware that this Practice has a privacy policy on handling patient information.

I acknowledge that I have read this form before signing it and that a member of staff of this Practice has at my request, clarified any aspects of it that I did not at first understand.

I also undertake to pay all fees owing to my Surgeon, including in the event that liability is denied or any outstanding accounts that have not been paid in full by my insurer.

Medicare Assignment of Benefit Agreement (Telehealth/Bulk-Billed Appointments)*

I agree to assign my Medicare benefit to the practitioner.

By checking this box, I (the patient/assignor) agree to assign my right to the Medicare benefit to the practitioner providing the care. I understand and agree that: The practitioner will accept a Medicare benefit as full payment for the service where applicable. A digital record of this agreement will be securely stored by the clinic for two years, and I can request a copy at any time.

Signature

Date

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