Workers Health Centre Consent Form "*" indicates required fields I understand I have a choice to nominate my own rehabilitation provider and I nominate the Workers Health Centre to be my provider.ProviderEmployerDoctorInsurance CompanyUnionReferrerSolicitorPsychologistPhysiotherapist/Exercise Physiologist.OtherConsent 1* I authorise Workers Health Centre to obtain information either verbal or written, in relation to my rehabilitation from relevant parties including but not limit to: treating partitioners (doctors, specialist, physiotherapist, psychologist , employer, insurance company and solicitor.*Consent 2* I authorise Workers Health Centre to release information concerning relevant aspects of my rehabilitation program to and discuss that information with relevant parties including treating practitioners, employer, insurance company and my solicitor. The information provided will be of a factual nature concerning the rehabilitation program and a copy of any relevant written report may be provided. I understand that this consent is required to assist with my rehabilitation and that all information obtained is treated in confidence. I also understand that I may change or cancel this authority at any time.*Consent 3* I authorise Workers Health Centre to release information concerning relevant aspects of my rehabilitation program to and discuss that information with relevant parties including treating practitioners (doctors, specialist, physiotherapist, psychologist), employer, insurance company and solicitor *Consent 4* The information exchanged will be of a factual nature concerning my rehabilitation. I understand that this consent is required to assist with my rehabilitation and that all information obtained is treated in confidence. I also understand that I may change or cancel this authority at any time.*Consent 5* I authorise Workers Health Centre (approved SIRA rehabilitation Provider) to use my records in an internal audit. I understand that I may change or cancel this authority at any time.*Name*Consent 6* I agree to the below statement.*I have read and understood, or had explained to me, the contents of the document Workers Health Centre Information Consent Form, which includes information about confidentiality and the requirements regarding disclosure and the use of information, as well as descriptions of the limits of confidentiality as stated under the Privacy and Confidentiality Act 2022, any information obtained by Workers Health Centre under this agreement will be maintained as confidential information. Files and reports will be maintained in a secure database. Please note in certain circumstances, some organisations are legally entitled to receive rehabilitation information about an injured worker, for example the insurer, SIRA, Safework NSW and a NSW Court of Law.Our privacy policy outlines the use and disclosure of your information and contains information on access, correction and complaints handling procedures – Privacy Policy.Signature of Injured Worker*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
