Patient Registration Form | Connected Radiation Therapy

Patient Details

Name(Required)

First Last

Phone number(Required)

Date of birth(Required)

Address(Required)

Street Address Suburb Postcode

Upload referral or relevant files

Drop files here or

Max. file size: 128 MB.

Have you had any relevant scans?(Required)

Yes

Where were the scans completed?

Privacy Consent

We collect your Personal Information from all of your documentation and information provided to us, including but not limited to your medical records, treatment plans, billing and insurance details. The types of information that Icon collects and records may include your name, address, telephone number, and Health Information such as the problem for which you seek treatment, the treatment advice provided and the results of any investigations or tests. We may also need to request further information related to your care from other external healthcare providers who are / have been involved in your care.

Do you consent to external healthcare providers releasing a copy of your medical records to A/Prof Sasha Senthi?(Required)

Yes

We may use your Personal Information:

To provide medical care and treatment to you
To update and keep current your medical records as required by our policies and law
To undertake billing activities, including liaising with private health fund insurers
To operate our facilities
To fulfil mandatory data reporting requirements and undertake compliance and quality assurance activities
To train our health professional staff
To comply with legislative and regulatory requirements, including but not limited to those relating to the Medicare Australia Act 1973 (Cth) and the Health Insurance Act 1973 (Cth)
For necessary and related ancillary purposes

We may disclose your Personal Information in strict compliance with all relevant privacy and data protection legislation (including but not limited to the Privacy Act 1988 (Cth)):

To medical practitioners, other hospitals or health service providers (including any applicable overseas medical practitioners or organisations) involved in your treatment or care (“Your Health Providers”). Where we have disclosed your Personal Information to Your Health Providers, they will disclose, store and access that Personal Information in accordance with their privacy policies and applicable privacy legislation and obligations
To Medicare, your private health fund or other hospital affiliated organisations (e.g. Department of Veterans’ Affairs)
To undertake health and medical research projects solely or in conjunction with related research organisations and external research organisations with whom we collaborate or partner (which may be based within or outside of Australia)
To related entities to facilitate internal business processes
To external agencies to undertake mandatory data reporting, compliance, quality assurance and accreditation activities
In an emergency where your life is at risk
To other third parties as may be required by law
To My Health Record in accordance with the My Health Record Act

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