Consent To Share Information Form Template – Australia

The Consent To Share Information Form Template – Australia is provided in multiple formats, including PDF, Word, and Google Docs. Each version is designed to be both customizable and easy to print, ensuring it meets your requirements effortlessly.

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Consent To Share Information Form Template – Australia

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1. Parties Involved



2. Purpose of Information Sharing

3. Types of Information to be Shared

4. Duration of Consent

5. Right to Withdraw Consent

6. Risks of Sharing Information

7. Confidentiality Statement

8. Governing Law

9. Signatures and Acceptance



PDF

WORD

Examples

Consent To Share Information Form Template – Australia (1)
Participant Information:
[Participant’s Full Name]
[Participant’s Date of Birth]
[Participant’s Address]
[Participant’s Phone]
[Participant’s Email]
Purpose of Information Sharing:
This Consent Form allows [Service Provider’s Name] to share the participant’s personal information with [Third Party’s Name] for the purpose of [specific purpose, e.g., coordination of care, research, etc.].
Information to be Shared:
Details of the information that may be shared include, but are not limited to:
  • Medical history
  • Contact details
  • Treatment plans
  • Billing information
Confidentiality and Data Protection:
The participant’s information will be handled in accordance with the Australian Privacy Principles and will be kept confidential. The information will only be shared with [Third Party’s Name] and for the stated purpose.
Duration of Consent:
This consent remains valid until [End Date], or until revoked by the participant in writing.
Right to Withdraw Consent:
The participant has the right to withdraw consent at any time by notifying [Service Provider’s Name] in writing.
Signature:
I, [Participant’s Full Name], consent to the sharing of my information as outlined above.
Signature: ________________________
Date: [Date]
Consent To Share Information Form Template – Australia (2)
Participant Information:
[Participant’s Full Name]
[Participant’s Date of Birth]
[Participant’s Address]
[Participant’s Phone]
[Participant’s Email]
Purpose of Information Sharing:
This Consent Form grants [Service Provider’s Name] permission to share the participant’s personal information with [Third Party’s Name] specifically for [reason, e.g., support services, case management, etc.].
Details of Information Shared:
The types of information that may be disclosed include:
  • Appointment history
  • Treatment details
  • Billing and payment information
  • Contact information
  • Emergency contacts
Confidentiality Assurance:
[Service Provider’s Name] will ensure that all shared information adheres to the Australian Privacy Principles and is treated as confidential.
Validity of Consent:
This consent is valid from [Start Date] until [End Date] and may be revoked at any time by the participant.
Participant’s Rights:
The participant is entitled to revoke this consent through written notice at any point in time.
Signature:
I, [Participant’s Full Name], agree to the sharing of my information as described above.
Signature: ________________________
Date: [Date]

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PDF – 1 PDF – 2

Consent To Share Information Form Template - Australia