I,

, as the Patient Associate Aunt Boy-Friend Brother Brother-in-Law Care Giver Cousin Daughter Daughter-in-Law De-Facto Partner Employee Employer Ex-Husband Ex-Partner Ex-Wife Father Fatrher-in-Law FiancÕe Foster Child Friend Girl-Friend Grand Child Grandparent Guardian Handicapped Dependent Husband Life Partner Manager Mother Mother-in-Law Nephew Niece None Other Other Adult Parent Sister Sister-in-Law Son Stepchild Trainer Uncle Unknown Ward of Court Wife of provide consent for St John of God Raphael Services to collect my/the patient's personal and health information on behalf of the various clinicians practicing at St John of God Raphael Services. I consent to St John of God Raphael Services and the clinicians to use and disclose my/the patient's personal and health information for the following purposes:

1. Collection of Personal Information
Global Health Demo Hospital collects your personal information and in particular your health information to provide you with a quality health service. The information will normally be collected directly from you. In emergency situations we may need to collect personal information from relatives or other sources where we are unable to obtain your prior consent.

2. Use of Personal Information
Health information is used by the hospital to provide treatment and care, to recover costs from Health Funds and other Insurance Agencies, in quality assurance and clinical audit and evaluation activities, for management, service monitoring, training and education, complaint handling and accreditation activities.

3. Disclosure of Personal Information
Global Health Demo Hospital is required by law to provide State and Commonwealth Health Department with data regarding episodes of care, treatment and as required diagnosis of a communicable diseases. Global Health Demo Hospital is also legally required to provide Health Funds with information about their clients who attend the hospital.

4. Privacy Questions/Complaints
Any questions about personal information handling practices, or any complaint regarding treatment of your privacy by Global Health Demo Hospital can be made in writing addressed to:

General Manager, Global Health Demo Hospital, PO Box 513 Varsity Lakes QLD 4227