METRO NORTH HOSPITAL AND HEALTH SERVICE

Oral Health Service

Proxy Access to Centrelink Information

First Name *

Last Name *

Email address: *

Address:

Street address

Suburb

Postcode

Date of Birth

Sex: *

MaleFemale

Which card type do you have? *

Pension Concession Card (PCC)Health Care Card (HCC)Department of Veterans' Affairs (DVA)

Dependant: *

YesNo

Customer Consent Script

This form is used for customers, 16 years of age and over, to provide consent for Queensland Oral Health Service staff to access Centrelink concession card information. This is to assess your eligibility in relation to concessions or services provided by the Queensland Health Oral Health Service. The Queensland Oral Health Service is committed to maintaining strict confidentiality in all aspects of service delivery

Customer Confirmation

I *

Authorise:

the Queensland Health Oral Health Service to use Centrelink Confirmation eServices to perform a Centrelink or Department of Veterans’ Affairs (DVA) enquiry of my Centrelink or DVA Customer details and concession card status in order to enable the business to determine if I qualify for services.
the Australian Government Department of Human Services (the Department) to provide the results of that enquiry to the Queensland Health Oral Health Service.

I understand that:

the department will use information I have provided to the Queensland Health Oral Health Service to confirm my eligibility for services and will disclose to the Queensland Oral Health Service personal information including my name, address, payment and concession card type and status.
this consent, once signed, remains valid while I am a customer of the Queensland Oral Health Service unless I withdraw it by contacting the Queensland Oral Health Service or the Department.
I can obtain proof of my circumstances/details from the department and provide it to Queensland Oral Health Service so that my eligibility for services can be determined.
if I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligible for the services provided by the Queensland Health Oral Health Service.

*

Customer/Guardian signature: *

Draw signature|Type signatureClear

Date signed *

Metro North Hospital and Health Service (Metro North) is committed to ensuring the privacy, security, accuracy, and integrity of personal information regarding all patients and individuals and agents associated with receiving or providing Metro North services. To protect your personal information, Queensland Health staff must follow the privacy principles contained in the Information Privacy Act 2009 (Qld) Staff are also bound by Part 7 of the Hospital and Health Boards Act 2011 (Qld) Your personal Information is being collected by way of this form to provide you with oral health services. The personal Information provided by you will be securely stored and made available to appropriately authorised staff of Queensland Health.Your personal information may also be disclosed to health practitioners who have in the past or will provide you with care or treatment, to staff of Queensland Health for the purpose of conducting assessment of the services provided to you or otherwise for the purpose relating to providing you with public sector health services. Personal information recorded on this form will not be used or disclosed to other parties without your consent, unless authorised or required by law.By ticking the box, I consent to Metro North Oral Health Service (MNOHS) collecting and using the information supplied while offering and providing dental treatment. I acknowledge that I have legal capacity to consent to treatment being provided for the patient whose details are recorded on this form. I acknowledge, understand and consent to the data being stored on the Snapforms Platform (as a Certified Cloud Service) which may include storage held within Australia. All information will be treated confidentially and only used for the purposes outlined above.For information about how Queensland Health protects your personal information or learn about your right to access your own personal information, please see our website at www.health.qld.gov.au.