I,

, as the Patient Aunt Brother Brother-in-law Carer Cousin Daughter Daughter-in-law Defacto Employer Ex-husband Ex-wife Father Fiance Friend Godfather Godmother Granddaughter Grandfather Grandmother Grandparent Grandson Guardian Husband Mother Mother-in-law Neighbour Nephew Niece Other Parent-in-law Partner Power of Attorney Self Sister Sister-in-law Son Son-in-law Step-Daughter Step-father Step-Mother Step-Son Uncle Wife of provide consent for Lakeview Private Hospital to collect my/the patient's personal and health information on behalf of the various clinicians practicing at Lakeview Private Hospital. I consent to Lakeview Private Hospital and the clinicians to use and disclose my/the patient's personal and health information for the following purposes:

1. Collection of Personal Information
Lakeview Private 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
Lakeview Private 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. Lakeview Private 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 Lakeview Private Hospital can be made in writing addressed to:

General Manager, Lakeview Private Hospital, 17-19 Solent Circuit, Norwest NSW 2153

Warning: Do not use the same e-mail address for more than 1 family member.