Thank you for your recent correspondence, requesting paperwork to be completed by your doctor or clinician at Eton Place.

As you can appreciate, should your doctor (or clinician) be unable to accommodate your request during your appointment, this, then, means that he or she will need to complete it outside of their consulting time, to ensure it is completed in as timely a manner as possible.

We trust you will understand that it is reasonable that the above process is remunerated. Hence, regrettably, all paperwork completed outside of your usual appointment time will incur a fee (as your doctor will often stay back after their clinic to complete these for you.

Please note that the above does not apply to usual/ expected correspondence back to your GP specialist or other members of your treating team.

Should the above process be acceptable to you and you would like to move forward with your request, please read and sign the below. Our team will then send through a quote and invoice for payment for completion of your paperwork.

Thank you very much for your flexibility and understanding.

Requesting letters/reports outside of your regular consultation

Please ensure you send through all the paperwork required to be completed, any additional information needed to complete your paperwork, as well as, information you would like your doctor/ clinician to be aware of and incorporate into your paperwork (eg, your perspective on specific questions/ answers etc).

Please also ensure you specify the date by which you require your paperwork completed and submitted or returned to you.

If your request is able to be accommodated, our administration team will inform you via email and specify the fee applicable to this request. An invoice will be provided and once paid, your completed paperwork will be returned to you (and/ or submitted to your elected third party) within 5-8 business days.

If your request is unable to be accommodated, our administration team will contact you via email, within 1 business day, to explain the reason for this (ie your doctor/ clinician is on leave etc).

Paperwork fees are billed in 15 minute durations (ie you will be billed in 15 minute increments). The fee is pro-rated from your doctor's (or clinician's) fee for 30 minute consultations. Please contact our administration team for a full breakdown of fees relevant to each of our clinicians.

Should your paperwork require urgent completion (ie 24 to 48 hour turnaround), please ensure you inform our administration team of this. A 50% surcharge fee will apply to this process.

I agree that I have read and understand the above information. *

Patient Details (who the requested paperwork is for)

Patient Full Name *

Patient Date of Birth *

Email Address *

Phone Number *

Request Details

Paperwork type: *

Letter (e.g. support letter for school/work)Report (e.g. detailed report for NDIS application)Form (e.g. completion of a form for Centrelink)

Urgency of paperwork request *

Routine: 5 - 8 business days Urgent: 24-48 hours turnaround time

I acknowledge and consent to paying the 50% surcharge for my request in addition to the routine paperwork request fee

Whom should the letter/report be addressed to *

Address for Letterhead *

Street address

City

State

Postcode

Upload form being requested or any additional information

Browse

Information the document must contain *

Information not to be included in document *

Paperwork Recipient Details

Email Address: *

Phone Number: *

Fax Number

Date document needed by *

Privacy and Confidentiality

Due to the Federal Privacy Act 1988, we require your written consent to collect personal information about you. Please read this information carefully and sign where indicated below.

We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat you. We may need to collect information from previous doctors, health care workers, pathology or x-ray services that you have consulted with, for the primary purpose of providing quality healthcare. This means that we will use the information you provide in the following ways:

Best assess your health care needs and provide medical treatment.
Administration purposes in running our practice. We may need to contact you using phone numbers provided by you. We may need to send documents, pathology and radiology referrals or letters to the email address provided by you.
Billing purposes and debt collection, including compliance with Medicare and Health Insurance Commission requirements.
Disclosure to others involved in your care, including treating doctors, specialists and hospital booking staff outside this practice. This may occur through referral to other doctors, surgery at hospitals, for medical tests and in the reports or results returned to us following the referrals.
Collection of data for research purposes. This information is used to improve our treatment protocols, which will enable us to improve our quality of care. The data is kept in a secure manner and only staff involved in the research has access to them. You may be contacted at some time in the future for follow up purposes. No information that can be used to identify you will be included in any publication of the research results. You may withdraw from the research at any time.
You may be contacted for follow up in the future to ensure the long term results of your procedure.

You have the right to see any health information we hold about you as well as the ability to correct any details that are not accurate.

I voluntarily consent that I have read and agree all information provided to me *

Full Name *

Date of Birth *

Signature *

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Date *