ࡱ> }|` jbjb |c|c ,    T 84DxT !#00dhLH""""""",Q$R&B" B"d B" "  8" 2 F  " @  $  "0!# S' S'  T T D dT T Consumer Consent toShare Information To record freely given informed consumer consent to share their information with a specific agency/ies for a specific purpose/s.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label hereSection 1: Proposed Information Uses and Disclosures The following service(s) are recommended. It is also recommended that relevant information is forwarded to the agency(s) that provide these services, in order that consumers receive the best possible care. Service Type Code: Examples: Physiotherapy Specialist consultantName of Agency Examples: Any agency Nominated clinicType of Information (including limits as applicable) Examples: All relevant information Test results only FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Section 2: Record of Consumer Consent 2(A) Written Consumer Consent Or2(B) Verbal Consent2(a) My worker/practitioner has discussed with me how, and why certain information about me may need to be provided to other service providers. I understand the recommendations and I give my permission for the information to be shared as detailed above. Signed: Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Signed by:  FORMCHECKBOX  Consumer OR  FORMCHECKBOX  Authorised Representative Name:  FORMTEXT       Witnessed: (Worker/Practitioner) Worker/Practitioner Name:  FORMTEXT       Position:  FORMTEXT      2(b) Worker/Practitioner Use Only Verbal consent should only be used where it is not practicable to obtain written consent. I have discussed the proposed referrals with the consumer or authorised representative and I am satisfied that the consumer understands the proposed uses and disclosures, and has provided their informed consent to these. Signed: (Worker/Practitioner) Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Worker/Practitioner Name:  FORMTEXT       Position:  FORMTEXT      To ensure the consumer is able to make an informed decision about consent to the disclosure of their information, the service provider should: (tick when completed) 1. Discuss with the consumer the proposed referral to other services/agencies(  FORMCHECKBOX  2. Explain that the consumers information will only be released to these services if the consumer has agreed  FORMCHECKBOX  and advise that the referral for service can still proceed if the consumer does not want information disclosed 3. Provide the consumer with information about privacy, such as the brochure Your Information Its Private  FORMCHECKBOX  4. Provide the consumer with a copy of this form if requested (see guidelines) once completed  FORMCHECKBOX  Produced by the Victorian Department of Human Services, 2006This information collected by:CCSI Page 1 of 1Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign:Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Consumer Consent to Share Information PRpr 46BNPdft  % & ` a b l haB*OJQJmH phsH  ha6CJ haCJha5B*CJ phj>haUjhaUj`haUjhaUjthaU ha5jhaUjhaUha/LNPdDv$$Ifa$l $Ifl $Ifl $Ifl $Ifl $Ifl  tvH r  RNL:($Ifl (kd$$Ifl Fd'd%  t 0'    2q22l2q4 l4alp  & ` $Ifl v$If^v`l d($Ifl ` a  6 ^ yeee<$Ifl kd$$IflF ' q 0'6    4 l4all m   $ & ( 2 4 6 8 L N P Z \ ^ ` b v x z    ڴکڞړڴڈjhaUjVhaUjhaUjhaUhaB*OJQJmH phsH jXhaUjhaUhajhaUmHnHujhaUjphaU3^ ` yeee<$Ifl kd$$IflF ' q 0'6    4 l4al  * R yeee<$Ifl kd$$IflF ' q 0'6    4 l4al   & ( * , @ B D N P R T V j l n x z | ~  4ڿڴکڞڿړڈj haUj haUjz haUj haUj haUhaB*OJQJmH phsH jh haUhajhaUmHnHujhaUjhaU3R T | yeee<$Ifl kd $$IflF ' q 0'6    4 l4al Fyeee<$Ifl kd $$IflF ' q 0'6    4 l4al468BDFHJ^`blnpr(*,68:<ڿڴکڞړڈڀhaB*phjhaUj<haUjhaUjhaUj*haUjhaUhaB*OJQJmH phsH hajhaUmHnHujhaUj haU2FHpyeee<$Ifl kd$$IflF ' q 0'6    4 l4al:yeee<$Ifl kd$$IflF ' q 0'6    4 l4al:<ywggg$Ifl kd$$$IflF ' q 0'6    4 l4alueeS$Ifl $Ifl kd$$IflF'0'6    24 l4a< &(*.068LNPXZrt246@BjhaUjhaUjhaUj*haUjhaUjJhaUjhaUmHnHujhaUjhaU ha5 ha6ha4\DZxSC$Ifl $x$&d(dIfPRl "$&d(dIfPRl <x$Ifl ( x$&d(dIfPRl & $&d(dIfPRl  ",fzS& f $&d(dIfPRl $Ifl $Ifl  dh$7$8$H$Ifl "x$&d(dIfPRl "$&d(dIfPRl 68LNPTV`bvxz~246@B&'(ںگڤڙڒڇjihaU jhaj:haUjhaUjZhaUjhaUjnhaU ha5 ha6hajhaUmHnHujhaUjhaU5Dx"x$&d(dIfPRl $x$&d(dIfPRl ( <$&d(dIfPRl  P$Ifl DF)yuooogS 9r $Ifl ' %' %xkd$$IflF'0'6    4 l4af,.PRfhvxz诠蚑{쑠shaOJQJjhaUj haUha5OJQJ ha0Jha5CJOJQJmH sH ha5CJOJQJmH sH jhaUjQhaha6Ujha6U ha6hajhaUjhaU(RB2%$Ifl #$Ifl kd9$$IflF ' 0'6    4 lal$$Ifl $ r  U"$Ifa$l .xo__"$Ifl kd$$Ifl0'  0'624 lalpxz(pk[[["$Ifl kd$$Ifl0 '  0'622U4 lalp&(HJ^`npr춨haCJOJQJmH sH haOJQJjS!haUha5OJQJj haUjs haUhajhaUjhaUprtvxzMK@>><& 1$5$7$8$9DH$ kd!$$IflF '    0'6    22U4 lalp ({. A!n"p#$%X" ,, g{HH(dh com.apple.print.PageFormat.FormattingPrinter com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.FormattingPrinter Acrobat_Distiller_Tancredi_on_localhost com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2005-10-26T22:33:29Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMHorizontalRes com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMHorizontalRes 300 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2005-10-26T08:50:57Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMOrientation com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMOrientation 1 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2005-10-26T22:33:29Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMScaling com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMScaling 1 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2005-10-26T22:33:29Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMVerticalRes com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMVerticalRes 300 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2005-10-26T08:50:57Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMVerticalScaling com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMVerticalScaling 1 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2005-10-26T22:33:29Z com.apple.print.ticket.stateFlag 0 com.apple.print.subTicket.paper_info_ticket com.apple.print.PageFormat.PMAdjustedPageRect com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMAdjustedPageRect 0.0 0.0 3508.3333333333335 2479.166666666667 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2005-10-26T22:33:29Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMAdjustedPaperRect com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMAdjustedPaperRect 0.0 0.0 3508.3333333333335 2479.166666666667 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2005-10-26T22:33:29Z com.apple.print.ticket.stateFlag 0 com.apple.print.PaperInfo.PMConstrainedPaper com.apple.print.ticket.creator CUPS_CPL com.apple.print.ticket.itemArray com.apple.print.PaperInfo.PMConstrainedPaper com.apple.print.ticket.client CUPS_CPL com.apple.print.ticket.modDate 2005-10-26T22:33:28Z com.apple.print.ticket.stateFlag 1 com.apple.print.PaperInfo.PMPaperName com.apple.print.ticket.creator CUPS_CPL com.apple.print.ticket.itemArray com.apple.print.PaperInfo.PMPaperName iso-a4 com.apple.print.ticket.client CUPS_CPL com.apple.print.ticket.modDate 2005-10-26T22:33:28Z com.apple.print.ticket.stateFlag 1 com.apple.print.PaperInfo.PMUnadjustedPageRect com.apple.print.ticket.creator CUPS_CPL com.apple.print.ticket.itemArray com.apple.print.PaperInfo.PMUnadjustedPageRect 0.0 0.0 842 595 com.apple.print.ticket.client CUPS_CPL com.apple.print.ticket.modDate 2005-10-26T22:33:28Z com.apple.print.ticket.stateFlag 1 com.apple.print.PaperInfo.PMUnadjustedPaperRect com.apple.print.ticket.creator CUPS_CPL com.apple.print.ticket.itemArray com.apple.print.PaperInfo.PMUnadjustedPaperRect 0.0 0.0 842 595 com.apple.print.ticket.client CUPS_CPL com.apple.print.ticket.modDate 2005-10-26T22:33:28Z com.apple.print.ticket.stateFlag 1 com.apple.print.PaperInfo.ppd.PMPaperName com.apple.print.ticket.creator CUPS_CPL com.apple.print.ticket.itemArray com.apple.print.PaperInfo.ppd.PMPaperName A4 com.apple.print.ticket.client CUPS_CPL com.apple.print.ticket.modDate 2005-10-26T22:33:28Z com.apple.print.ticket.stateFlag 1 com.apple.print.ticket.APIVersion 00.20 com.apple.print.ticket.privateLock com.apple.print.ticket.type com.apple.print.PaperInfoTicket com.apple.print.ticket.APIVersion 00.20 com.apple.print.ticket.privateLock com.apple.print.ticket.type com.apple.print.PageFormatTicket tDText1vDText64vDText64jDtDText3tDText4$$Ifl!vh5d55%#v%#v#vd:V l  t 0'5%55d/ / 2q22l2qalp $$Ifl!vh5 5q 5#v#vq #v :V l0'6,55q 5 4altDText5tDText6tDText7$$Ifl!vh5 5q 5#v#vq #v :V l0'6,55q 5 4aljDjDtDText7$$Ifl!vh5 5q 5#v#vq #v :V l0'6,55q 5 4altDText5tDText6tDText7$$Ifl!vh5 5q 5#v#vq #v :V l0'6,55q 5 4altDText5tDText6tDText7$$Ifl!vh5 5q 5#v#vq #v :V l0'6,55q 5 4altDText5tDText6tDText7$$Ifl!vh5 5q 5#v#vq #v :V l0'6,55q 5 4altDText5tDText6tDText7$$Ifl!vh5 5q 5#v#vq #v :V l0'6,55q 5 4altDText5tDText6tDText7$$Ifl!vh5 5q 5#v#vq #v :V l0'6,55q 5 4al$$Ifl!vh555#v#v#v:V l0'6555/ / / / /  24vDText64vDText64jDtDeCheck3tDeCheck3tDText8tDText8tDText9vDText64vDText64jDvDText10vDText11$$Ifl!vh555#v#v#v:V l0'6555/ 4tDeCheck3tDeCheck4tDeCheck5tDeCheck6$$Ifl!vh5 55#v#v#v :V l0'6,555 /  / 4al$$Ifl!vh55 #v #v:V l 0'65 5/ / 24alpvDText12vDText13$$Ifl!vh5 5#v#v :V l 0'6,55 /  / 22U4alpvDText64vDText64jDvDText152$$Ifl!vh5 5 5 #v #v #v :V l 0'6,5 5 5 /  / 22U4alp)@@@ NormalOJQJ_HmH sH tH L@L Heading 1$@&5B*CJ<OJQJphDA@D Default Paragraph FontZi@Z  Table Normal :V 4 l4a _H(k@(No List \O\ A Heading A dCJ,OJQJmHnHsH tH uJOJ DHS Text 10pt1$5$7$8$9DH$NON DHS Text 12pt1$5$7$8$9DH$CJTO"TA Main SubheadOJQJmHnHsH tH uBOB DHS Report Hd 25CJbOBbA Consumer Head d5OJQJmHnHsH tH udORdA Consumer text dCJOJQJmHnHsH tH u<Ob< tableB*CJOJQJphb"@b CaptiondTd7$8$H$ B*CJOJQJmH phsH u`O` A Heading BdTdCJOJQJmHnHsH tH u^O^ A Body textd<7$8$H$CJOJQJmH sH tH >P@> Body Text 2 6OJQJlOl A Table headingd7$8$H$!B*CJOJQJmH phsH tH F @F Footer 1$5$7$8$9DH$ 9r .)@. Page Number4@4 Header  !nOnA small captiondx "6CJ OJQJmHnHsH tH uBOB A Body small dCJROR A Body small indent!^`HO1"H A Footer left"  U"5hO2hA Footer bold left#d8"5CJOJQJmHnHsH tH uHO1BHA Footer bold right$$a$>O!R>A Footer right%$a$\Ob\ A side title&$a$"5CJOJQJmHnHsH tH uHOrH A Body 5mm tab'^`ZOZA Draft(/5@,B*CJ<OJQJmHnHphsH tH u)*+ )*+.  ^*^ "& &";Znor&`au,@TUi}  2TUijohp1<S  e W ) & K L R 0ˀ0ˠ0ˠ0ˀ0Й0Й0Й0Й0ˠ0ˠ00000 00 00 0 0Й0Й0Й0 0Й0Й0Й0 0Й0Й0Й0 0Й0Й0Й0 0Й0Й0Й0 0Й0Й0Й0 0Й0Й0Й0 00 0 0 0 00000Й0Й0Й000Й0Й0 0000000Й0Й0Й0 0'0Й'0Й'0Й'0Й0 0 $0 0 #0 %0 0 "0Й"0Й0 "0 "0Й"0Й0 0&00 @no  (N" tx/:ptwww/ppa.c.elD/mo @ l  4<"%(, ` ^ R F:Dxp !#$&')*+-.  '39FRXamsu$*,8>@LRUagiu{} )/my* 6 9 ? K N R ^ c  ' 7  '   $ 7 C I e q t | FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFG G FFFFFFFFG G$G$G$FFFFFF@  @H 0(   (  r  6  B S  ? Ax$=tText1Text3Text4Text5Text6Text7Text8Text9Text10Text11Check3Check4Check5Check6Text12Text13Text15(Gbvn (   8  :Yt 8 ( % J nor`au,@TUi}  2TUij & K L R "@ %%Q%%nnn @  @4@UnknownGTimes New Roman5mstr `Symbol3 ArialA Arial Narrow7 Verdana 1h*&Df|F^ !4d T`a%Consumer Consent to Share InformationRobert Di RenzoRobert Di Renzo Oh+'0 $ <H d p | '&Consumer Consent to Share InformationdRobert Di RenzoPConsumer Consent LO 6A.dotnRobert Di Renzo3PMicrosoft Word 11.1@@@jV@0^ GdPICT\Z HHZ ZHHy,ZZ  s7c^sc^so{s Zc^Z^ZNskZ6RcRBBZ=BRF1sRcRBBRBBs6JRRJRF15==B5F1sJRRJRF151F19s?o{ss^g9kZskZs^so{kZsZcZ^s@JRRcJRZF1JRBRg9RJRcs5F1JRBV=^RBcs@NsJRZRJRV-k=9ZRVVs9F1VB99VJRF1Vs>sRcVcg9NskZVVZRZkZg9kZkZssY%scZNs^NsVNsVNs^V^g9cJRVZ^Z^F1Vc^Z^^Ns^ssZ^g9sH sc^ZZBsNsZF1cR^ZNsZ^ZJRRNsZV^^JR^ss, sccNsZVNsg9ZF1Z^VZs$s ZRZ^ZZ^css's cVZg9VZR^^Rsss kg9{{s{kZg9o{{o{o{g9{{{sw{ss{{o{g9ww{s{{s2V9RckZNsNskZwZ9F1NsJRF1B==cJRg9Bc=Ns^g9JRF1JRBNsBVg9=R=JRJRcF1JRwKc^F1VcVcc^ZkZ^VVkZR^kZcZZNsZ^Z^VcJRkZ^kZcZ^cZJRVZkZ^JRcc^cJRZcNsckZRcVcR^ZZV^c^cZkZF1co{ i&cVg9RJR^cNs^ZkZ^^VcF1^co{kZcc^JRkZcRkZ^JRV^Z^ZcBkZVZ ! sVo{g9VNsg9^Vwwwss NsZZNsZR^V^^g9kZg9^VZwVVo{ZRJR^RkZZc^cRRg9kZg9g9^g9^co{ZkZVcVg9g9ZckZg9ZNskZkZckZZkZVcVg9so{RkZkZg9RkZkZZkZVcVg9sZVkZckZg9RkZg9NskZRg9-o{^cckZkZZ^g9RZo{? o{Vg9F1kZZg9kZZkZ o{cg9Nsg9g9Rg9g9kZUg9{{s{g9g9s{o{{kZkZw{{kZw{{s_V9RckZNsNsRwRkZ)JNscBNsg9^sNsNsJR g9F1c^sNsNsJRF1NsciRwVkZo{B^wZ^ZJRo{Vo{wJRZV^g9wo{ Bw^Vo{VZg9Z^ZV^g9 'g9VkZg9RkZ$Rcc^Z^ZVkZ^^g9^Z^kZc^kZg9kZkZNsRg9Z^g9^cZg9ccg9g9NsZR^RkZV^Nsc^Rc^ZcZ&kZ^^ZZRo{Z^^g9^c^g9R^Z^g9g9^^cRc^cVg9Z^V^^Z^o{$^F1ckZkZcc^cZ^cF1ccZZ^^cJRc^^RkZNscco{] kZ^Z^^cVg9Z^^wcVkZRNsRZcZZVc^o{NskZcNskZ&Zg9c^^Rg9cZ^VkZ^ZZ^g9c^^g9Rg9Vg9Z^Zg9c^R^kZVg9Ro{Z^g9^c^kZg9kZkZ^cZ^cVc^kZ^cBF1cRZ^SZ^ZRR^^g9RcRg9^Vc^kZc^Bc^c^g9^wQ kZ^g9RRo{^Vg9Z^cVcVkZ^g9RR^^g9cRZGkZ^R^cZ^kZZ^kZ^g9Rg9Vg9g9c^^Rg9cZ^ZVcJRsQcVc^kZ^cg9kZ^kZ^g9cc^kZVkZg9VkZZg9cg9^kZcVg9YRcVVZRZkZg9kZkZZ^o{ZRR^ckZ^g9kZ^JRZ^kZ^wcZVcJRZg9sc^JRkZZR^^VcV^ZR^cRcNsZ^RZVNsZs^=ZcZV3RZVZZRZkZg9kZkZNsNs^ccJRs3NsZR^RkZV^Nsc^RcZ^s^=?NsZR^RkZckZNscNskZZNsVZc^VcsZc^Vcs cc^c^RVRc>^JRkZVcZRZZc^cckZcJRZ^ZZRVVccZc^^cc^cZV^ZNsVc^Rc^^kZVRRc^ccR^c^ZkZ^ =cVg9RRc^cF1ZkZ^c^ckZcZcRVZkZ okZwRVkZNscc^V^kZcc^Z^^NsVc^ZRRkZc^co{^Rc^ZkZ^Vc^cRc  g9wZg9JRkZcVcVRc+^JRg9cVRRcNscckZccZZ^RRccJRZV^c^cRZRcZV^kZcc^Z^RcR^Z,ccZNsg9V^Vco{V^RRkZVNsV^ZkZ^kZcZkZcVkZ^JRF1^kZccNsZ^kZZNscZccNsRRc^ccF1kZVcJR  Ag9wZVg9R^V^kZcc^Z^kZc^kZcRRcNsccZc^ZkZRkZcc^kZNscV^ZVkZ^^Rg9^g9RRR^^g9^kZg9ZZ^Rw 8kZwZVg9R^V^kZcc^Z^kZc^ckZccRg9VkZcRRZRc^cVZkZNs^c^R^V^VccRkZcZcRVZ Kg9^kZg9o{VkZZkZo{^o{g9^kZco{RkZg9^ZNsZkZo{o{kZZ^c Css^JRZNsg9R^ZRg9ZcZcsZZ^g9g9cZc^ss.sVg9Vcs^cF1c^cVsDs^ZcsZg9ZcNsVVg9s Zcc^R^V^c^ss      ՜.+,0 hp  ' Aria Design  &Consumer Consent to Share Information Title  !"#$%&'()*+,-./0123456789:;<=>?@BCDEFGHIJKLMNOPQRTUVWXYZ[\]^_`abcdefhijklmnopqrsuvwxyz{~Root Entry FNData A"1TableSS'WordDocumentSummaryInformation(gPDocumentSummaryInformation8tCompObjX FMicrosoft Word DocumentNB6WWord.Document.8