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The Consent To Disclose Personal Health Information Form is a critical document used throughout Australia's healthcare system to ensure proper authorization for sharing patient health information. This document is essential when healthcare providers need to share patient information with other providers, institutions, or authorized parties. It must comply with the Privacy Act 1988 (Cth), the Australian Privacy Principles, and relevant state-specific health records legislation. The form is designed to protect patient privacy while facilitating necessary information sharing in healthcare settings. It is commonly used in situations such as referrals to specialists, insurance claims, continuity of care between providers, and research purposes, where explicit patient consent is required for information sharing.

1. Patient Information: Patient's full name, date of birth, contact details, and any relevant identification numbers (e.g., Medicare number)

2. Healthcare Provider Details: Information about the healthcare provider/organization requesting consent, including name, contact details, and provider numbers

3. Purpose of Disclosure: Clear statement of why the health information is being disclosed and how it will be used

4. Information to be Disclosed: Specific details of what health information will be disclosed, including time period covered

5. Recipient Details: Information about who will receive the health information, including organization names and contact details

6. Duration of Consent: Timeframe for which the consent remains valid, including expiry date if applicable

7. Privacy Statement: Statement explaining how the information will be protected and handled under privacy laws

8. Declaration and Signature: Patient's acknowledgment and signature section, including date and witness details if required