Participant Consent Form

  • We collect information about you for the primary purpose of providing quality supports and services to you. We need to collect some personal information from you to ensure our services meet your needs. If you do not provide this information, we may be unable to fully provide these services. This information will also be used for:

    • a. administrative purposes for running our service
    • b. billing through a third party
    • c. use within our service to ensure you are provided with quality supports and services
    • d. disclosure of information to a third party, or other government agencies if needed
    • e. disclosure of information to health care professionals, specialists or other individuals/companies providing you with support and/or care to ensure high quality health care for you if needed
    • f. disclosure to other providers, with your consent, in order to provide appropriate services.

    We do not disclose your personal information to overseas recipients.

    We have a privacy policy that is available on request. That policy provides guidelines on the collection, use, disclosure and security of your information.

    To ensure the process of quality supports and services, information about you may be given to other service providers who also provide you services.

    By signing below, I confirm I:

    • have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure
    • understand that it is my choice as to what information I provide and that withholding or falsifying information might act against the best interests of the supports and services I receive
    • am aware that I can access my personal information and shift notes on request and if necessary, correct any information I believe to be inaccurate
    • understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me
    • have been provided with or have been given an opportunity to obtain a copy of the privacy policy
    • consent to provide my personal information to Enriched Health Care
    • consent to have my personal information shared to service providers listed below:
  • Date Format: DD slash MM slash YYYY
  • Date Format: DD dash MM dash YYYY

  • Personal Information Collection Statement

  • You may contact us by email, mail or phone using the details provided at the bottom of this page. You have the right to gain access to the information we hold about you.

    Our privacy policy (available upon request) contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

    We need to collect information about you for the primary purpose of providing quality supports and services. In order to fully provide these services, we need to collect some personal information from you. This information will also be used for the administrative purposes of running the practice such as billing you or through the NDIS. Information will be used within the service for planning and managing your plans and supports.

    We may disclose information regarding you to other service providers or health professionals only with your consent. We will not disclose your information to commercial companies, however specific service or product information as deemed suitable for your management, may be forwarded to you by us, unless you instruct us not to forward this type of information. Your written consent will obtained at the start of any new planned activities. We do not disclose your personal information to overseas recipients.

    File information is stored securely and access only by our workers. We take all reasonable steps to ensure that information collected about you is accurate, complete and up-to-date. You may have access to your information on request and if you believe that any of the information is inaccurate, we may amend it accordingly. If you do not provide relevant personal information, in part or in full, this may result in the provision of incomplete supports or services which may impact on your plans and goals. Any concerns you may have about this statement or the information we store about you can be directed to the contact listed below.


    Name: Rebecca

    Enriched Health Care

    Phone Number: (02) 6583 6900

    Address: 3/133-137 Gordon St, Port Macquarie NSW 2444

    Email: support@enrichedhealthcare.com.au