No PO Boxes

Please enter at least one phone number

A medicare number is 10 digits
This is the number next to your name on your Medicare card
Senior's Health Care Card not applicable

Please enter the number associated with your Hospital cover (not Extras). We require this specifically for any potential surgical procedures that take place in a Hospital or Day surgery facility. Note: Your Extras cover (dental, physio, optical) does not cover consulting room fees or scans.

Please include name & phone number
We require a referral on the day of your appointment from a GP, optometrist or specialist in order to process Medicare claims.
Browse
If you already have your referral you may upload it here. You may upload a PDF, word document or photo of the referral.
Please include name, clinic name and suburb. If you do not have a referral yet, please note this above.
Please include doctor's name, medical practice name and suburb. If you do not have a regular GP, please note this above.
Please include optometrist name (if known), optometrist clinic and suburb

If the next button is not clickable, please check you have entered at least one phone number above.


Parent/ Guardian/ Next of Kin Details 

If your child is under the age of 14, we require your details in order to submit a medicare claim.


PRIVACY POLICY

Forest Eye Surgery respects your privacy. This policy has been prepared in accordance with the requirements of the HealthRecords and Information Privacy Act 2002 (NSW) and the Federal Privacy Act 1988. This includes both the Australian PrivacyPrinciples – Commonwealth Privacy Amendment (Enhancing Privacy protection Act 2012) and the NSW Health Privacy Principles.This document sets out how information may be collected and used, and the rights and responsibilities in the collection, storage anduse of that information.

1. Collection: The information collected is used for the purpose of providing treatment to you. The information we collect and hold may include: name, address, telephone numbers, date of birth and marital status, occupation, next of kin details, GP, referring doctor and optometrist details, financial details associated with services the practice has provided, medical history, current and past records of treatment given at this practice and any additional information provided to the practice by the patient.

2. Use and Disclosure: We use the information you provide us to provide you with appropriate clinical treatment and care in our practice, assist with any calls a patient may make to us, for our internal administrative requirements, to process Medicare & health fund claims, to provide information to medical practitioners and other health professionals who provide follow up treatment & ongoing care, for clinical indicator reporting in a de-identified form and to provide data in both an identified and deidentified form to government agencies in compliance with numerous legislative requirements.

3. Information storage: We store your information in paper based documents in secure storage within the practice and in electronic format with restricted access and appropriate security controls.

4. Access: Your medical history and any other material relevant to your treatment will be kept by us. You may request copies of our records of your treatment at any time by written request. You do not have to provide a reason. Information will be checked prior to release for accuracy and completeness and to ascertain whether any information should be withheld for safety or legal reasons.

5. Legal requests: Confidential information from medical records are only released to solicitors or other third parties upon receipt of a current written consent by the patient, or where appropriate, their legal representative who has the power of attorney. The request should specify the dates of treatment pertinent to the information being sought and must be the original signed version, not a copy. Statutory fees may apply for this service depending on the amount of information requested. Subpoena requests will be handled promptly upon receipt of the original request and kept on your file. Fees charged for workers compensation and subpoena requests are $33 for the first 30 pages, then $1 per page.

6. Amendment: If a patient believes that personal information we hold about them is incorrect, incomplete or inaccurate, they may request amendment of it in writing. This request will be reviewed by the attending doctor and the request and the outcome willbe documented in the medical record.

7. Questions and complaints: Any questions about this policy, or any complaint regarding treatment of a patient’s privacy bypractice, should be made in writing by the patient to the Practice Manager by emailing admin@foresteyesurgery.com.au

Signing this form indicates that you have read the above and consent for Forest Eye Surgery to have your personal and health information collected

Draw signature|Type signatureClear