CONSENT FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Download Consent Form PDF Download Consent Form Docx Please enable JavaScript in your browser to complete this form.By filling this form you give consent to Recoverycare Australia to collect the required personal information *FirstMiddleLastEmail *Date of birth *Kindly enter your date of birth in the format as shown above.NDIS Number: *For implementation of the NDIS plan, and to administer, evaluate and monitor its services and activities.If required, I give consent to Recoverycare Australia to disclose this information to: (Please tick the relevant person’s/agencies)Australia HealthThe NDIA*NDIS Support CoordinatorsGeneral PractitionersAllied Health ProfessionalsPublic Trustee and GuardiansNext of KinEmergency Services for the benefits of its consumers*I know I can withdraw my consent at any time, either in writing or verbally informing the Well care Australia management team. This consent ceases to have effect when the participant/staff leaves the program, or 12 months from the date of signing (whichever comes first).This consent form was completed by the:NDIS ParticipantGuardian or another responsible personClient/ Guardian’s signatureDateTerms and Agreement *I understand and agree to the terms.Disclaimer: *Due to duty of care obligations Recoverycare Australia cannot provide support to participants who withhold consent to release personal information to the NDIA and emergency services.Submit
