Client Consent Form

My Care Planner (‘we, ‘us’, ‘our’) is committed to preserving the privacy and security of our clients’ (‘you’, ‘your’) personal information and we are aware of our obligations under the Australian Privacy Principles contained in the Australian Privacy Act 1988.

The personal information we process about you will include information about your physical and mental health and condition. We use your personal information to provide, manage and administer supports for you. If we do not have this personal information, we may not be able to provide, manage or administer the supports you have requested. In addition to this, we may also share your personal information:

with other professionals to assist them in providing supports to you;
with people that you request or permit us to keep informed of our activities in connection with you. If you do not wish us to share your personal information with any such person, please note the details of such person(s) in Section C entitled ‘Keeping Others Informed’;
with third party service providers so that they can provide services to you;
to comply with any domestic or foreign laws and regulations that apply to us; and
to respond to demands and requests by domestic and foreign regulators, governments and law prevention, detection, investigation and enforcement authorities, tax, social or labour authorities, customs authorities and other authorities or official bodies, courts, tribunals, arbitrators, ombudsmen, mediators and dispute resolution bodies and their representatives, and professional and self-regulatory bodies.

Are you the NDIS Participant or the Guardian/Nominated Representative? *

Client Consent

I consent to the use of my personal information for the purposes set out in this form and in accordance with my preferences set out below.

Participant's Signature *

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Name *

Date *

Guardian/Nominated Representative Consent

I am authorised to act on behalf of the client named below and I consent on behalf of the stated client for the use of their personal information for the purposes set out in this form and in accordance with the preferences set out below. I also consent to my personal information being used to administer this consent and to provide evidence of this consent to third parties.

Guardian/Nominated Representative's Signature *

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Guardian/Nominated Representative's Name

Participant's Name

Date Signed *

Keeping Others Informed

Irrespective of any request received, I direct you not to provide my/the client’s personal information to the following individuals and/or organisations:

In addition to the categories of people set out in this form, I do consent for you to disclose my/the client’s personal information to the following individuals and/or organisations:

Other Consents

Occasionally My Care Planner may wish to use your/the client’s personal information for the purposes set out below. Please indicate for which (if any) of the purposes below you give your consent for My Care Planner to use your personal information.

I give consent for My Care Planner to use my/the client’s personal information for the purposes of departmental/internal auditing and reporting processes.

I give consent for My Care Planner to use my/the client’s name, age and/or suburb for marketing purposes.

I give consent for My Care Planner to use my/the client's positive feedback for marketing purposes.