ࡱ> y{xa jbjb11 *h[[ ,  jjj8\ .f "#$D-------,/R92- L$"""L$L$-+ ;.+++L$ ` 8 -+   L$-++ @ + Tj'@++lQ.0.+2+2++ j jConsumer 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 Service Type Examples:  Physiotherapy  Specialist consultantName of Agency Examples:  Any agency  Nominated clinicType of Information (including limits as applicable) Examples:  All relevant information  Test results onlyPurpose/s Examples:  Referral  Care coordination FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       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 Consumer ConsentThe worker/practitioner has discussed with me how and why certain information about me may be shared with other service providers. I understand this and I give my informed consent for theinformation to be shared as detailed above. Signed: Dated: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Signed by:  FORMCHECKBOX  Consumer OR  FORMCHECKBOX  Authorised representative on behalf of:  FORMTEXT       (Consumer) Witnessed by: Signed: (Worker/Practitioner) Dated: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Worker/Practitioner Name:  FORMTEXT       Position:  FORMTEXT      Worker/Practitioner Use Only Verbal consent should only be used where it is not practicable to obtain written consent. I have discussed with the consumer/consumers authorised representative how and why certain information may be shared with other service providers. I am satisfied that this has been understood and that informed consent for the information to be shared as detailed above has been given. Signed: (Worker/Practitioner) Dated: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Worker/Practitioner Name:  FORMTEXT       Position:  FORMTEXT      To ensure the consumer/consumer s authorised representative is able to make an informed decision about consent to the sharing of information as detailed above, the worker/practitioner should: (tick when completed) 1. Discuss with the consumer the proposed sharing of information with other services/agencies  FORMCHECKBOX  2. Explain that the consumers information will only be shared with these services/agencies if the consumer has agreed  FORMCHECKBOX  and, when referring, advise that 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, 2009This 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 46BNPdftb 8 `  ( x z | ~ #h<B*CJOJQJmH phsH hs lh<CJ h<6CJ h<CJj>h<Ujh<Uj`h<Ujh<Ujth<U h<5jh<Ujh<Uh<0LNPdDv $$Ifa$$If$If$If$If$If TnH b v RK@00v$If^v` ($Ifgd<(gd<kd$$Ifl Fd'd%  t 0'    2l2l2q24 l4alp   8 `  ( < R z $Ifgd< $Ifgd<v$If^v` ($Ifgd<v$If^v`gd<z |  aWWWW <$Ifkd$$Ifl\O (e  0 (64 l4al      4 6 8 B D F H \ ^ ` j l n p ڹڧڜڑچjh<Ujth<Uj h<U#h<B*CJOJQJmH phsH jh<Uj_h<Ujh<Uh<jh<UmHnHujh<Ujwh<U2  F n aWWWW <$IfkdG$$Ifl\O (e  0 (64 l4al     & ( * 4 6 8 : N P R \ ^ ` b d x z | ڽڲڧڜڑچj h<Uj h<Uj h<Ujq h<Uj h<Uj h<U#h<B*CJOJQJmH phsH h<jh<UmHnHujh<UjRh<U3  8 ` aWWWW <$Ifkd$$Ifl\O (e  0 (64 l4al` b aWWWW <$IfkdY $$Ifl\O (e  0 (64 l4al (*,.BDFPRTVjlnxz|~ڽڲڧڜڑڽچjBh<Uj h<Ujh<Uj#h<Ujh<U#h<B*CJOJQJmH phsH jx h<Uh<jh<UmHnHujh<Uj h<U3,T|aWWWW <$Ifkd $$Ifl\O (e  0 (64 l4alFaWWWW <$Ifkd$$Ifl\O (e  0 (64 l4al  468BDFHJ^`blnprڲڧڜڑچڲj1h<Ujh<UjIh<Ujh<U#h<B*CJOJQJmH phsH jh<Uj*h<Uh<jh<UmHnHujh<Ujh<U2FHpaWWWW <$Ifkd$$Ifl\O (e  0 (64 l4al=>[aXRRR$If<gd<kd$$Ifl\O (e  0 (64 l4alJS[\*0DPQRS_`jk&(*.068LNPXZprtʷʩʷʊʷ|jNh[@jh<Ujh[@jh<U jh[@jh<UmHnHujbh[@jh<Ujh[@jh<Uh[@jh<5 h[@jh<h<0J+B*phh[@jh<0J+B*phh<h<B*phh[@jh<B*ph.[\DL\ufI* x$&d(dIfPR $&d(dIfPR $Ifgd<kdh$$IflF'0'6    24 l4a\r$LdZox$&d(dIfPRgd<" x$&d(dIfPRgd<  P$If P$Ifgd< f $&d(dIfPR <x$Ifgd< <x$If $&:<>HJd$&(,.46JLNVXZ}jh[@jh<Ujh[@jh<Ujh[@jh<Uh[@jh<5hYHh<5 jh[@jh<UmHnHujh<Uj,h<Uh< h[@jh<jh[@jh<Ujh<U/.2345ABLM&(*.068LӽȬӟӊ|ȬnȬjh[@jh<UjXh[@jh<Uh[@jh<5hs lh<0J+B*phh[@jh<0J*B*ph jh[@jh<UmHnHujh<Ujh[@jh<U h[@jh<jh<UmHnHujlh<Uh<jh<U%..\f" x$&d(dIfPRgd< P$Ifgd<  f $&d(dIfPRgd< $Ifgd< $Ifgd<$If dh$7$8$H$Ifx$&d(dIfPRLNPXZ\89GHI56DEFʷ©Ξʓʈʃyiyj; h<h<6Ujh<6U h<6jh<UjSh<Uj$h<Ujh<UmHnHujh<Ujh<Uh< h[@jh< jh[@jh<UmHnHujh[@jh<UjDh[@jh<U'\Q?;xkd$$IflF'0'6    4 l4ax$&d(dIfPRgd<x$&d(dIfPRgd<QG$$If$ r  U"$Ifa$  9r $If' Q':x^`:gd<' Q':^`:gd<!'()01;< 02FHVXZdf(*>Ļ|j%h<Uj]%h<Uj$h<Uh<OJQJji#h<Uj"h<Uh<5OJQJ h<0Jh<5CJOJQJmH sH h<5CJOJQJmH sH h<jh<Uj h<U-({uo%$If#$Ifkd#!$$IflF ' 0'6    4 lal()Xoii"$Ifkd!$$Ifl0'  0'624 lalpXZfPkeee"$Ifkd#$$Ifl0 '  0'622U4 lalp>@NPRTVZ\`bfhr h?h<h<h<CJOJQJmH sH h<OJQJjh<Uj=&h<UPRTXZ^`dfMKIIIIII kd&$$IflF '    0'6    22U4 lalpfjlnpr & ({. 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