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Patient/Consumer Consent Form for Choice Aged Care Services

I, or my authorised representative, understand and consent to the provision of the following services (where indicated and/or referred for):

Medicine Review (Home or Residential) service

Nurse Practitioner (NP) service

Geriatrician service

Risks and Benefits: I have had the opportunity to ask questions about treatment, risks, benefits, and alternatives. Any questions have been answered to my satisfaction. 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.

Confidentiality: My personal health information will be kept confidential according to the law and Choice Aged Care’s privacy policy. This policy can be accessed at: https://www.choiceagedcare.com.au/wp-content/uploads/2024/05/CAC-Privacy-and-Confidentiality-Policy.pdf

  1. If referred for, 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 for an authorised person 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 services. 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.