NEW PATIENT DETAILS AND CONSENT

General Information

Patient first name *

Patient surname *

Date of birth *

Known as

Email Address (or enter n/a) *

Primary phone number *

Alternate phone number

I give permission to be contacted by SMS as required. I understand that I may opt out of SMS communications at any time by contacting the office on 02 4956 3440.

I agree to being added to the Telehealth waitlist and understand I may be contacted without notice for an initial appointment with A/Prof Hansen, that the standard initial consultation fee applies, and that calls may come from an unknown or no caller ID, including outside normal business hours.

Home address (as per Medicare card) *

Street address *Street address line 2

City *

State *

Postcode *

Emergency Contact Information

Emergency contact full name

Phone

Emergency contact’s relationship to you

Do you consent to us giving this person your results and appointment information?

YesNo

Medicare, Insurance, DVA, Healthcare/Pension card details

Medicare Number/ref (e.g., 1234567890/1) *

Private Health Fund *

Membership Number *

Level of HOSPITAL cover (if unsure please contact your Health Fund - ***If you are a HCF Member - DIAMOND, RUBY, EMERALD & OPAL are NOT a level of hospital cover) *

Are you in a waiting period with your Health Fund? *

YesNo

Health fund wait period - If you ticked yes - please provide the date you joined

Private hospital insurance which covers a potential surgery in a private hospital is a pre-requisite for an appointment with A/Prof Mitchell Hansen in his private rooms. If you do not have private health insurance (or active DVA entitlements or WorkCover claim) then your referral needs to be faxed to the Referral Management Centre at John Hunter Hospital - Fax: 49223900 for you to go on the waitlist to see A/Prof Hansen at his Outpatient Clinic there. Consult your referring doctor to assist with this. If applicable, your referral must have a completed Spine Clinic form attached. You would be bulk billed at this clinic.

Please continue to complete this form.

DVA No

DVA Card Colour

WhiteGold

White card accepted condition

WorkCover Insurer

Claim Number

If your appointment is related to an approved WorkCover or Third Party claim, a written approval from your insurer is required prior to making an appointment.

Unfortunately A/Prof Hansen is not currently accepting new Third Party claimants as patients. Please redirect your referral to another Specialist.

Healthcare/Pension card number

Expiry date

Health Information

Usual GP

Address

Additional medical condition/s and treating Specialist

If you have had any recent MRI or CT scans please list the name of your imaging provider/s

Consents

PATIENT INFORMATION CONSENT

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in yourhealth care needs. We will use the information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements and debt collection agencies.
Disclosure to others for the purpose of managing your health, including treating doctors, specialists and allied health providers, including their non-clinical staff.
Disclosure to insurance companies and solicitors (in the case s of workers compensation or third party insurance).
Disclosure to Courts, tribunals or as required by law.
Medical Research
- I understand the reasons why my information must be collected.
- I understand that I am not obliged to provide any information requested of me, but that my failure to do so might
  compromise the quality of the health care and treatment given to me.
- I am aware of my right to access the information collected about me, except in some circumstances where access mightlegitimately be withheld. I understand I will be given an explanation in these circumstances.
- I understand that if my information is to be used for any purpose other than the above, my consent will be sought.
- I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on
  access or disclosure of which I may notify this practice.

FINANCIAL CONSENT

The fees below are payable whether your consultation is provided face to face or via Telehealth (phone/video call). Full payment is required on the day for your consultation. We can submit your claim to Medicare.

Initial Consultation: $400 (Medicare rebate $127.35)
Follow up Consultation: $275 (Medicare rebate $84.15)

NOTE TAKING CONSENT

We utilise a note taking tool called Heidi to accurately and efficiently capture the details of our discussions and the outcomes of our appointments. Your information will be handled with the utmost care, and Heidi’s use is aimed solely at improving your healthcare experience.

I confirm that above information I have provided is true, complete and accurate. *

By signing this consent form, you are agreeing to the above patient information, financial and note taking consents.

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