Participant Acknowledgement and consent Form

Participant Acknowledgement and Consent form

Authority to Collect, hold, use and disclose participant information

Privacy Act 1988

Personal information collection, holding, use and disclosure of personal information by this Company is protected by the Privacy Act 1988 (Cth).

Personal information is any information or an opinion that identifies you or could identify you and includes information about your health.

The purpose for collecting personal information from you is to:

provide services, including planning, coordinating, funding, implementing, monitoring and reviewing our services

report to NDIA, government or other funding bodies of how funding is serviced by us,

responding to your feedbacks, and

responding to your queries.

* Please note that Kapital Care Pty Ltd is required to release information about service users (without identifying you by full name or address) to the NDIA and to the Australian Institute of Health and Welfare, to enable statistics about disability services and their participants to be compiled. The information will be kept confidential. This information is used for statistical purposes only and will not be used to affect your entitlements or your access to services. As a user of National Disability Agreement services you have the right to access your own files and to update or correct information included in the Disability Services National Minimum Data Set collection.

This Company will not disclose/use information about you for any secondary purpose unless:

You have consented to the use or disclosure
You would reasonably expect us to use or disclose the information for the secondary purpose as it is directly related to the primary purpose
The use or disclosure of the information is required or authorised by or under an Australian law or a court/tribunal order
Our Company reasonably believes the use or disclosure is necessary to lessen or prevent a serious threat to life, health or safety of an individual or to public health and safety
Our Company has reason to suspect an individual may have done something unlawful or engaged in serious misconduct that relates to Company functions or activities.

Our Company reasonably believes that the use or disclosure is reasonably necessary to assist another person to locate a person reported as missing.

Part A: Participant details

Note: If you are not the participant and you are a child representative, plan nominee or legally appointed decision maker, please complete this section about the participant you are representing.

First name *

Last name *

Date of birth *

Email address *

NDIS participant number *

Preferred contact details(phone number, email address, etc.)

Part B: Child representative, plan nominee, legally appointed decision maker details

Please provide your details in this section if you are completing this form on behalf of a participant:

under 18 years for whom you have parental responsibility, or a child representative
for whom you are a plan nominee, or
for whom you are a legally appointed decision maker (for example, a guardian).

The NDIA may ask you to provide confirmation that you are authorised to represent the participant and to verify your identity.

Please mark the relevant box below to indicate your relationship to the participant

Child representativePlan nomineeLegally appointed decision maker

Participant representative full name

Preferred contact details(phone number, email address, etc.)

3.2c Please mark the relevant box below to indicate the length of time you are providing the consent for

Ongoing

For the duration of my current NDIS plan

For a set time ending (DD/MM/YYYY)

Until I withdraw consent

Once only

Any other information

If so, please specify what this information is below:

Privacy and your personal information

Participant Consent for Third Party Release of Information

Pursuant to Privacy Act 1988 (Cth) and The Health Information Protection Act

The purpose of this form is to provide consent to the release of personal information to third parties as requested by the Participant which is protected and governed by the privacy provisions of the Privacy Act 1988 (Cth) and The Health Information Protection Act

I give consent to Kapital Care Pty Ltd of 139B Uriarra and Davison Road, Crestwood NSW 2620 and 02 61130692 or 0478578804

Personal information which the Company, or its staff need to release in order to respond to the following concern or issue:

Information regarding my information needed to implement my supports, his/her NDIS plan.
I understand this may include personal information within the meaning of The Freedom of Information and Protection of Privacy Act, and personal health information within the meaning of The Health Information Protection Act.
I further understand that the Company will only release as much information as is needed to respond to my concern and subject to the restrictions and provisions of The Freedom of Information and Protection of Privacy Act 1988(Cth) and The Health Information Protection Act.

Consenting to the Release of Personal Information

In order to comply with privacy legislation, this consent is necessary when participants ask third parties to either advocate or make inquiries on their behalf regarding various issues or services provided by the Company.
In all cases, the Company will only release as much information as is needed in order to respond to the inquiry or participant’s concern.
Certain information will not be released by the Company e.g. information about other individuals, records subject to solicitor-participant privilege, records relating to a current lawful investigation, records the release of which would affect the safety or health of anyone).
In the event a subsequent inquiry is made by the same third party which is unrelated to any previous participant concern, another consent form will need to be completed.

Acknowledgement of receipt of information from Kapital Care

my rights and responsibility's, including my right to access a support person of my choice, such as an advocate, in my dealings with Kapital care.

My Privacy rights and Kapital care legal obligations with respect to sharing information

Kapital Care , the services offered and other supports available.

How to access, leave or re-access Kapital care services

Conditions that may apply to service provision.

Kapital care uses the NDIS pricing guide, Kapital care have outlined their fees and charges in my service agreement.

The process for providing feedback or making a complaint.

Part D: Your declaration

I give authority for the Company; to collect, store, use and disclose personal and sensitive information, including health records, for the primary purpose of service provision and directly related needs in accordance with the Privacy Act 1988 (Cth) whilst I/we remain a participant of this Company.

If my/our circumstances change I agree to notify Kapital care Pty Ltd as soon as practicable.

Note: Where a participant does not have the capacity to give informed consent and does not have a legal guardian who has the authority to make decisions on behalf of the participant, the participant’s parent, family member or other person with a close personal relationship to the participant may sign this form. The person who signs on the participant’s behalf must print their relationship to the participant next to their name.

Please send completed forms to Kapital Care Pty Ltd

I understand I can withdraw or change my consent to share information and/or my permission for a third party to act on my behalf at any time.

Signature

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Name

Date

If you are not the participant, please mark the relevant box below to indicate your relationship to the participant

Child representativePlan nomineeLegally appointed decision maker (please provide the NDIA with details of this appointment if not already provided)

Part E: Your delegate's declaration

Please note: This section is only to be completed if you, the participant, is unable to sign this form in Part D. Instead, your chosen ’delegate’ must be aged 18 and over and can sign in the presence of a witness.

Signature of participant’s delegate

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Name of participant’s delegate

Signature of witness

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Name of witness

Date

Witness certification (please mark each box below):

I certify this document was signed by the delegate in the presence of the person providing consentI certify that consent was provided freely and voluntarily; andI certify that the person providing consent has decision making capacity in relation to the provision of consent provided.

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