Complete Choice

0414 890 464 / 0466 057 770

info@completechoice.com.au

39 John St, Salisbury, SA 5108

F36 Participant Information Consent form

F36 Participant Information Consent form

Part A: Data Collection Information
Information about your needs allow for your provision of services so our team can:
 decide if we can provide a service that suits your needs
 develop a person-centred plan
 create a roster/schedule
 develop an individual medication plan (if applicable)
 share information with support staff
 share information with other providers or people to develop a comprehensive plan
This form allows you to tell us who we can and cannot share information. If you decide to withdraw your permission
after signing this form, you can update your consent by contacting management
Privacy Information
Privacy and confidentiality
Personal information collection, holding, use and disclosure of personal information by this Organisation is protected by
the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) (Privacy Act).
Personal information is any information or an opinion that identifies you or could identify you and includes information
about your health.
Any personal information held by our Organisation is protected under the National Disability Insurance Scheme Act
2013 and the Privacy Act 1988. Our Organisation will only disclose relevant and/or necessary information to any
external parties you have permitted us to disclose information unless required by law.
Personal information and documents
The purpose for collecting personal information from you is to:
 provide services, including planning, coordinating, funding, implementing, monitoring and reviewing our services
 report to NDIS, government or other funding bodies of how funding is used by us,
 take photographs and videos for therapeutic and marketing purposes
 responding to your feedback, and
 responding to your queries.

* Please note that our organisation is required to release information about service users (without identifying you
by full name or address) to the Disability Services Commission and to the Australian Institute of Health and Welfare,
to enable statistics about disability services and their participants to be compiled. The information will be kept
confidential. This information is used for statistical purposes only and will not be used to affect your entitlements or
your access to services. As a user of National Disability Agreement services, you have the right to access your own
files and to update or correct information included in the Disability Services National Minimum Data Set collection.

This Organisation will not disclose/use information about you for any secondary purpose unless:
 You have consented to the use or disclosure; or
 You would reasonably expect us to use or disclose the information for the secondary purpose as it is directly related
to the primary purpose; or
 The use or disclosure of the information is required or authorised by or under an Australian law or a court/tribunal
order; or

Our Organisation reasonably believes the use or disclosure is necessary to lessen or prevent a serious threat to
life, health or safety of an individual or public health and safety; or
 Our Organisation has reason to suspect an individual may have done something unlawful or engaged in serious
misconduct that relates to organisational functions or activities;
 Our Organisation reasonably believes that the use or disclosure is reasonably necessary to assist another person
in locating a person reported as missing.

*Authority to Act as an Advocate form must be completed and placed in participant’s file.

Acknowledgement

I understand that all information provided by me or about me remains confidential unless I agree to disclose to others. I understand I can change this consent at any time by contacting designated point of contact or our office
I am providing my consent:

Part B Consent

1. Giving consent (sharing information)

I give consent and permission for this Organisation to collect and hold my personal information
I consent to disclose information to the following people and/or organisations; please the box for services that you agree we can receive and share information with, specific to your support service needs;

Complete the Person/Agency relevant to the individual participant

Consent
Type of Information
Purpose of information**

Consent
Type of Information
Purpose of information**

Consent
Type of Information
Purpose of information**

Consent
Type of Information
Purpose of information**

Consent
Type of Information
Purpose of information**

Consent
Type of Information
Type of Information
Purpose of information**

Consent
Type of Information
Type of Information
Purpose of information**

Consent
Type of Information
Type of Information
Purpose of information**

* Add relevant people of agencies –Doctors, Allied Health, Plan Managers, SIL/SDA providers, education providers
**SA – Service Agreement; SP – Support Planning – planning, implementing, monitoring and reviewing

2. Specific consent

2. Specific consent

Allow to assist with medication (refer to Management of Medication documentation, if yes)

Money Management
Where required and requested support the participant to access and spend their own money as the client decides

Assist with handling money

Media
Profile photos may be taken to assist with the delivery of services. These photos will not be published outside of our
management system and key reference documents e.g., support plan, medication care plan. Usage will comply with
Australian Privacy Principles and adhere to our Privacy and Confidentiality policies

Photographs and videos for purposes of support provision only
Photographs and videos for purposes of support provision only

NDIS Audit (opt-out)
As registered Disability Service Providers, we are obligated to undergo regular audits to comply with our legal
requirements. Part of this audit process involves auditors contacting some clients to discuss the services you
receive and your level of satisfaction. We are seeking to confirm if you give your consent for the auditors to contact
you and review your file and records
Your participation is not compulsory. You can opt-out if you do not want to be involved.

I consent to participate in an audit if approached by the auditor
give authority for the Organisation; to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs under the Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) whilst I/we remain a participant of this Organisation. I am aware that recorded material in audio and/or visual format and outline can be shared without consent if required by law

If my/our circumstances change, I agree to notify this Organisation as soon as practicable.

Name
Name
First
Last

Maximum file size: 15MB

Note: Where a participant does not have the capacity to give informed consent and does not have a legal guardian who
has the authority to make decisions on behalf of the participant, the participant’s parent, family member or other people
with a close personal relationship to the participant may sign this form. The person who signs on the participant’s behalf
must print their relationship next to their name.
Please send completed forms to our Organisation.
Participant Consent for Third Party Release of Information
Pursuant to The Privacy Amendment (Enhancing Privacy Protection) Act 2012 (Cth) and The Health Information
Protection Act
The purpose of this form is to provide consent to the release of personal information to third parties as requested by the
participant which is protected and governed by the privacy provisions of The Privacy Amendment (Enhancing Privacy
Protection) Act 2012 (Cth) and The Health Information Protection Act.

I understand this may include personal information within the meaning of The Freedom of Information and Protection
of Privacy Act and personal health information within the meaning of The Health Information Protection Act.
I further understand that the Organisation will only release as much information as is needed to respond to my
concern and subject to the restrictions and provisions of The Freedom of Information and Protection of Privacy Act
2012 (Cth) and The Health Information Protection Act.

Maximum file size: 15MB