Consent Form and Confidentiality Agreement

Therapy requested
It is understood and agreed to that the below identified discloser of confidential information may provide certain information that is and must be kept confidential. To ensure the protection of such information and to preserve any confidentiality necessary, it is agreed that:
It is the responsibility of all Nursing Essentially (NE) workforce members, as defined above, including: employees, sub-contractors, consultants medical staff and other health care professionals; volunteers; agency, temporary and registry personnel; and students (regardless of whether they are NE trainees or rotating through NE facilities from another institution), to preserve and protect confidential client, employee and business information. Nursing Essentially handles all information according to the Privacy Principles as described in the Australian Commonwealth Privacy Act (1988). This is clearly delineated on Nursing Essentially’s website at: http://www.nursingessentially.com.au/privacy-policy/ The client is advised that Nursing Essentially will only collect personal information necessary for our business functions or activities. This includes: o providing you with our services; o providing you with information you may have requested and answering your enquiries; o providing you with the information we consider of interest to you – but please remember that we will always ask for your permission first. Confidential Client Information includes: Any individually identifiable information in possession or derived from a provider of services regarding a client’s medical history, mental, or physical condition or treatment, as well as the clients and/or their family members records, test results, conversations, research records and financial information. Examples include, but are not limited to: o Physical medical and psychiatric records including electronic, paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples; o Client insurance and billing records; o Drivers licence or photographic identification records; o Mainframe and department based computerised client data and alphanumeric radio pager messages; o Visual observation of clients receiving medical care or accessing services; and o Verbal information provided by or about a client.
This e-Signature typed here confirms that this Consent Form is a true and correct statement of fact and constitutes full agreement of terms and conditions as described herein.