By providing my personal information (including health information) in this form, I consent to the following:
A: My personal information (including health information) will be shared with HealthStrong Pty Ltd ABN 61 155 277 919 trading as Amplar Allied Health for the purpose of providing allied health services such as physiotherapy, occupational therapy and podiatry (Services).
B: Amplar Allied Health will contact me about the Services. If Amplar Allied Health is unable to contact me after three attempts, it will contact my nominated next of kin and ask them to request that I call Amplar Allied Health to discuss next steps. No personal and/or health information contained in this form will be disclosed to my next of kin as part of that contact.
C: If applicable, Amplar Allied Health may be required to disclose my personal information to my health fund, or an authorised agent of my health fund, to ascertain private health insurance eligibility for the Services, confirm receipt of the Services and facilitate my participation in the Services. All parties involved in the Services are bound by strict obligations of confidentiality and privacy.
Where I am completing this form on behalf of a client or other individual, I confirm I have informed them of, and obtained their consent to, each of the matters referred to above.