Home Medicine Review (HMR): I acknowledge I have read or had explained to me, and understand, the Home Medication Review Service.

Nurse Practitioner (NP) Service: I understand that I am receiving healthcare services from Choice Aged Care NP to diagnose, manage, or treat my medical condition(s) as discussed with my healthcare provider.

Telehealth Services: I understand that Choice Aged Care offers NP telehealth services (telephone or video consultations) using secure communication methods to ensure confidentiality and privacy.

Risks and Benefits: I understand that all treatments, including telehealth, have potential risks and benefits. Specific risks include limitations on physical examination and potential technology issues. Benefits include increased access to care and convenience.

Questions and Understanding: I have had the opportunity to ask questions about the treatment, risks, benefits, and alternatives. My questions have been answered to my satisfaction.

Confidentiality: My personal health information will be kept confidential according to the law and Choice Aged Care’s privacy policy. Identifiable information will only be shared with those involved in my care unless I give specific permission otherwise.

Privacy policy can be viewed here: https://www.choiceagedcare.com.au/wp-content/uploads/2024/05/CAC-Privacy-and-Confidentiality-Policy.pdf

1. I consent to receive the HMR Service and to the collection of my personal information by the Pharmacy Programs Administrator and the Australian Government Department of Health and Aged Care to enable the pharmacy to claim a payment for delivery of that service and for program monitoring and evaluation purposes.
2. Consent for Nurse Practitioner Telehealth Services:
   I consent to the proposed treatment or procedure, including telehealth services, conducted securely to protect my privacy.
3. Consent for Case Conferencing:
   I consent to members of the Care Choice Services Team attending case conferences if required for my care.
4. Consent for Representation in Limited Circumstances:
   I consent to a person authorized to act on my behalf if I am unable to participate fully. By indicating consent has been obtained, I acknowledge that I have read and understood the information provided above and consent to the proposed HMR, including NP telehealth services if required. If you are indicating consent is provided on behalf of the intended service recipient, please indicate your relationship to the patient in the comments field provided e.g. Parent or guardian of child Enduring Guardian (recognised by a relevant state or territory law), Enduring Power of Attorney, (recognised by a relevant state or territory law), A person who has been nominated in writing by the patient while the patient was capable of giving consent, A person recognised by a relevant state or territory law.