I,

, as the Patient Aunt Bishop Brother Brother-in-law Carer Caseworker Cousin Daughter Daughter-in-law Defacto Doctor Employee Employer Ex-defacto Executor Ex-husband Ex-wife Father Fiance Friend Friends Godfather Granddaughter Grandfather Grandmother Grandparent Grandson Guardian Housekeeper Husband Minister Mother Mother-in-law Neighbour Nephew Next of Kin Niece Other Parent-in-law Parents Partner Power of Attorney Self Sister Sister-in-law Solicitor Son Son-in-law Spouse Step-father Step-Mother Step-Son Superior Uncle Unknown Wife of provide consent for Monash House to collect my/the patient's personal and health information on behalf of the various clinicians practicing at Monash House. I consent to Monash House and the clinicians to use and disclose my/the patient's personal and health information for the following purposes:

1. Collection of Personal Information
Monash House Private Hospital collects your personal information and in particular your health information to provide you with a quality health service. The information will normally be collected directly from you. In emergency situations we may need to collect personal information from relatives or other sources where we are unable to obtain your prior consent.

2. Use of Personal Information
Health information is used by the hospital to provide treatment and care, to recover costs from Health Funds and other Insurance Agencies, in quality assurance and clinical audit and evaluation activities, for management, service monitoring, training and education, complaint handling and accreditation activities.

3. Disclosure of Personal Information
Monash House Private Hospital is required by law to provide State and Commonwealth Health Department with data regarding episodes of care, treatment and as required diagnosis of a communicable diseases. Monash House Private Hospital is also legally required to provide Health Funds with information about their clients who attend the hospital.

4. Privacy Questions/Complaints
Any questions about personal information handling practices, or any complaint regarding treatment of your privacy by Monash House Private Hospital can be made in writing addressed to:

General Manager, Monash House Private Hospital, 271 Clayton Road, Clayton VIC 3168