I hereby agree to consent to treatment by an appropriately qualified provider for the purpose for providing comprehensive services as may be necessary in support of my illness, injury or condition. I have been given the opportunity to read clinic information prior to treatment. I understand I have the right to decline part or all of the treatment being offered. I understand my right to a second opinion.
AGREEMENT TO PAY:
I understand that I am liable to pay for:
- Any private treatment or copayment charges for ACC treatments and/or any treatment that is declined by ACC or other funder
- If I fail to attend my appointment or cancel without 24 hours notice I may be charged a $50 fee
- If I fail to pay for my appointment at the time of treatment I may be charged an account administration fee
- The costs of materials such as orthotics, materials, products etc
- I understand that if this service requires engaging a Debt Recovery Service to recover my debt, I will be liable for any recovery fees.
CONSENT TO RELEASE INFORMATION TO A 3rd PARTY(Privacy Act 1993):
I consent to the disclosure of my records to any person/organisation necessary for the effective management of my condition.
I consent to a discharge/update report being sent to my doctor or medical centre.
I DECLARE - That the information I have given in this form is true and correct.
I AUTHORISE - ACC to collect medical and other records which are or may be relevant to my claim. The treatment provider to lodge this claim for me.