PRIVACY INFORMATION AND CONSENT

We require your consent to collect personal information about you. Please read the following information about privacy issues, practice requirements and fees carefully, before you agree and accept our terms and conditions.

The eDiet – Health & Nutrition collects information from you regarding your history for the primary purpose of providing quality health care. We ask you about your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs.

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

• Administration purposes in running our practice
• Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
• Disclose to others involved in your health care, including treating doctors and specialists outside this This may occur through referral to other doctors, or for medical tests and in reports or results returned to us following the referrals.
• Disclosure to other doctors in the practice, locums, and medical students and by Registrars attached to the practice for the purpose of patient care and
• In an emergency situation where it is in the best interest of your health care we would disclose appropriate information if requested to do

ACKNOWLEDGEMENT

I have read the information above and understand the reasons why this information must be collected. I am also aware that this practice has a privacy policy on handling patient information.

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 legitimately be withheld. I understand I will be given an explanation in these circumstances.

I understand that if my information is to be used for any other purpose other than set out 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 limitation on access or disclose that I notify the practice of.

I agree to receive clinic’s appointment reminders with SMS, email or to link with patient’s portal (if any).

I agree to abide by the following practice procedures:

It is my responsibility to make sure I have a current/valid referral from my GP for each visit to be eligible to claim Medicare rebates as also it is clinically important for us to have the information they need.

If I fail to attend an appointment and/or do not give more than 24 hours’ notice of my cancellation, I may be charged a non- attendance fee as per clinic’s policy 100% of the consultation fees.

I understand that the cost of the consultation is above the Medicare schedule fee, which means that I will incur an out of pocket expense and I am responsible for payment of all services rendered on my behalf and on behalf of my dependents regardless of the length of the consultation. I agree to pay the account in full at the time of the consultation as per table below.

I have read this form before accepting/signing all above terms and conditions and a member of staff has, at my request, clarified aspects of it that I have not understood.

DEBIT ACCOUNT AND CREDIT CARD PAYMENT AUTHORISATION

By accepting/signing all terms and conditions you hereby authorise eDiet – Health & Nutrition to debit your bank account or credit/debit card shared, for each session on the day of consultation. This is permission for the amount to be charged as per our fees described below. Any additional costs for extended sessions or further assessments cannot be charged without confirmation from the client. This authorisation does not provide authorisation for any additional unrelated debits or credits to your account except of the cancellation fees and/or any extra admin fees. You accept that you authorise the above-named business to charge your bank account or credit/debit card indicated in this authorisation form according to the terms outlined above. This payment authorisation is for the services described above, for the session cost only or any cancellation fees or extra admin costs. You certify and confirm that you are an authorised user of this bank account or credit/debit card.

Private Health Insurance Claims also available.

FEES TABLE FOR FACE TO FACE (F2F) CONSULTATIONS AND TELEHEALTH APPTS

Duration	Appointment Type & Description	Private Fee	Medicare Rebate	Out of Pocket
40min	Initial Appointment	$140.00	$58	$82
20min	Review	$100.00	$58	$42