Fillable Client Consent Form reby give consent to Rehability (Australian National University)

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Client Consent Form reby give consent to Rehability (Australian National University)

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PO Box 336, Morningside, Qld, 4170 | PH 07 3161 2471 | www.rehabilityaustralia.com.au | admin@rehabilityaustralia.com.au
V1 Mar 2021 Page 1 of 1
Client Consent Form
I,
Of (
address):
He
reby give consent to Rehability Australia (ABN: 62 132 347 990) to provide services; and in
providing these services, I give consent for:
Rehability Australia to obtain and/or release information regarding their service provision to:
☐ Significant other/Partner/ Spouse
☐ Family
☐ Doctors/Medical Specialists
☐ Service Provider (care agency)
☐ Allied Health Providers
☐ Employer
☐ NDIA/NDIS
☐ DVA/ADF
☐ Funding Body/Insurer
☐ Other:
☐ Sig
nificant other/Partner/ Spouse
☐ Family
☐ Doctors/Medical Specialists
☐ Service Provider (care agency)
☐ Allied Health Providers
☐ Employer
☐ NDIA/NDIS
☐ DVA/ADF
☐ Funding Body/Insurer
☐ Other:
A c
ommunication tree is a system of communication set up as an email group to notify key
stakeholders of specific information, events, and updates to ensure open and transparent
communication with all parties.
☐ I confirm that I have read and understood that Rehability
Australia is a fee for service
organisation and I/my funder will be invoiced for services provided.
☐ I confirm that I have been advised of the ‘Privacy and Information Management’ policy of
Rehability Australia.
I would like this consent form to (please specify preferred option and desired date):
☐ be reviewed on:
☐ expire on:
Client / Representative Signature
Name:
Signature:
Date:
Witness Signature
Name:
Signature:
Date:
AND agree to the following parties in a ‘communication tree’ to assist with managing my needs:
17-Mar-2021
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Client Consent Form reby give consent to Rehability (Australian National University)

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Completed 24 February 2022

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