Assignment and Release
Treatment as a Private Patient
As you will be treated as a private patient, please note that payment is required on the day of your consultation. Consultation fees in this practice do not exceed those considered fair and reasonable. They are however higher than the Medicare benefits schedule of fees.
Concession, pension and DVA card holders are accepted.
For procedures performed in Private Hospitals, a Patient Gap is usually payable. Should there be any issues regarding the payment of these fees or gaps, please discuss them directly with Dr. Vun at the time of your appointment.
We would be grateful if you could provide adequate notice (>3 days) if you need to reschedule your appointment.
During your treatment, it will be necessary to collect and store information about you. This is collected by our practice team and is accessed by the specialist and staff during your care.
We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat illnesses and be proactive in your health care. In accordance with the Privacy Act (1988) all information collected in this way is treated as ‘sensitive information’. To protect your privacy, this practice operates in accordance with the Act.
This specialist practice collects information from you for the primary purpose of providing quality health care. You can assist in maintaining the accuracy of your information by advising the practice of changes of details including contact and medical information.
The information provided will also be used in the following ways:
Administrative purposes in running our medical practice.
Billing and medical rebate purposes, including compliance with Medicare and other government
Disclosure to others involved in your health care (including treating doctors and specialists inside
and outside this medical practice, hospitals to which you are admitted and providers of diagnostic services), which may occur through referral to other doctors, or for medical tests and in the reports of results returned to us following the referrals. The use of digital photographs in web-based consultations with pathologists and other specialists may also occur with your permission to assist in your health care.
Disclosure for research and quality assurance activities to improve individual and community health care and practice management. Information used outside of this practice will be de-identified.
There may be occasions when disclosure of your information is required for medical defence purposes or legal requirements to disclose personal information for mandatory reporting e.g. communicable diseases.
Your medical information may also be used beyond providing health care, such as professional accreditation, research, quality assessments and clinical auditing.
We will not discuss medical conditions or appointment information with anyone but the patient (if over 16) without their signed consent. This includes all relatives and spouses.
I understand and consent to the above.
I understand that I am not obliged to provide any information requested of me but that my failure to do so may compromise the quality of healthcare and treatment given to me.
I consent to the access of medical records and results held by other parties, such as radiology and pathology companies, and other hospital including private and public institutions that I may have visited, where access and review would be clinically relevant to my care.
I am aware of my right to access information collected about me, except where access might legitimately be withheld (for which I will be given an explanation) and that there may be costs involved. I understand that if my information is to be used for any other purpose than that set out above, my further consent will be obtained.
I certify that the information I have supplied is true and correct to the best of my knowledge.
I accept full responsibility for accounts rendered by Dr Simon Vun Pty Ltd including any shortfall in reimbursement by Medicare, Workers Compensation schemes, Health Funds or insurance companies. I have been offered information relating to costs at this practice.
If I am uninsured whilst being treated as an inpatient or day patient in a private hospital facility, I accept personal responsibility for full payment of my specialist’s account.
I understand that total specialist fees for procedures and treatments cannot always be accurately quoted but only estimated in advance.
I have not altered the content of this form without verbally notifying the practice and treating practitioner and obtained the practitioners signed agreement.
I have read and accepted the above: