Consent Form

• I give consent to MedHealth Pty Ltd (t/as mlcoa) to:
  • collect, hold and use my personal and health information for the purpose of this assessment service;
  • contact me in relation to my request for this assessment service;
  • directly access and review further medical records e.g. hospital notes and other clinical records, imaging and pathology test results etc, at my request, if relevant to the purpose of this assessment; and
  • at my request, contact my treating medical practitioner(s) to discuss my personal and health information and, receive from my treating medical practitioner, my personal and health information if relevant to the purpose of this assessment.
• I acknowledge that I:
  • have had access to, read and understood the mlcoa Information Privacy Statement that outlines how and why certain personal information about me may be collected, held, used and disclosed by mlcoa;
  • have had access to read and understood information regarding the purpose of the assessment service; (Assessment Information Sheet)
  • have had the opportunity to seek further information as necessary from a representative of mlcoa; and
  • may revoke consent at any time by written notification to mlcoa but this will not affect any action already taken by mlcoa prior to the receipt of my written notification of revocation.
• In providing this consent I understand mlcoa will NOT disclose any personal and health information collected about me to my health/life insurance fund (Insurer). The only exception is where mlcoa may provide my name, date of birth and a reference number which may identify me to my Insurer for the sole purpose of mlcoa confirming with the Insurer your eligibility to access this Service, where an eligibility check is applicable, and for the purpose of billing the Insurer for this service.
• If indicated, I give consent to the medical specialist expert to contact me to discuss my personal and health information as part of formulating and providing their specialist medical opinion.
• I understand that the medical specialist expert may suggest that I attend mlcoa’s or the specialist’s offices to undergo a physical examination. If I choose to undergo the examination, I agree that I will not be required to sign a further consent form and that the consent I give in this form will cover that examination.

Consent for child

• I am the parent/guardian of the child named in the Consent Form who is to receive the assessment service.
• I give consent to MedHealth Pty Ltd (t/as mlcoa) to:
  • collect, hold and use my child’s personal and health information for the purpose of this assessment service;
  • contact me in relation to my request for this assessment service;
  • directly access and review further medical records relating to my child e.g. hospital notes and other clinical records, imaging and pathology test results etc, at my request, if relevant to the purpose of this assessment; and
  • at my request, contact my child’s treating medical practitioner(s) to discuss my child’s personal and health information and, receive from my child’s treating medical practitioner, my child’s personal and health information if relevant to the purpose of this assessment.
• I acknowledge that I:
  • have had access to, read and understood the mlcoa Information Privacy Statement that outlines how and why certain personal information about my child may be collected, held, used and disclosed by mlcoa;
  • have had access to read and understood information regarding the purpose of the assessment service; (Assessment Information Sheet)
  • have had the opportunity to seek further information as necessary from a representative of mlcoa; and
  • may revoke consent at any time by written notification to mlcoa but this will not affect any action already taken by mlcoa prior to the receipt of my written notification of revocation.
• In providing this consent I understand mlcoa will NOT disclose any personal and health information collected about me to my health/life insurance fund (Insurer). The only exception is where mlcoa may provide my name, date of birth and a reference number which may identify me to my Insurer for the sole purpose of mlcoa confirming with the Insurer your eligibility to access this Service, where an eligibility check is applicable, and for the purpose of billing the Insurer for this service.
• If indicated, I give consent to the medical specialist expert to contact me to discuss my child’s personal and health information as part of formulating and providing their specialist medical opinion.
• I understand that the specialist may suggest that my child attend mlcoa’s or the specialist’s offices to undergo a physical examination. If I choose for my child to undergo the examination, I agree that I will not be required to sign a further consent form and that the consent I give in this form will cover that examination.

Terms and conditions

1. Disclaimers

• These terms and conditions should be construed in accordance with consumer protection legislation (Australian Consumer and Privacy Laws).
• Your health/life insurance fund (Insurer), mlcoa and medical specialist expert make no representations in relation to this mlcoa Service and whilst reasonable care is taken in facilitating this Service, there are no expressed or implied warranties nor guarantees associated with the accuracy, quality, completeness, suitability, reliability, or currency of any information, opinion, advice or report provided as part of the service, or their usefulness in achieving any purpose.
• You agree and acknowledge the following:
  • Specialist medical expert’s opinion is limited to, and based on, a medical records review and any discussion with you.
  • Specialist medical expert may not have access to all information usually available from the member’s own treating doctor(s).
  • The Service is for informational purposes only. The Service is intended solely for members and not for other persons.
  • Members should rely on their own assessment and enquiries to verify accuracy of information etc.
  • The Service does not replace/substitute professional medical advice. Any questions or concerns arising from this Service should be discussed with the member’s treating doctor(s) before making any decisions or taking any action based on the Service.
  • Reliance on advice/opinion as part of this Service is at the member’s sole discretion and responsibility.
  • You must not use this Service if you have a current claim in relation to, or have lodged a complaint against, any health practitioner or health service.

For the purposes of mlcoa and these terms and conditions, a member is a person deemed eligible by the relevant Insurer to access mlcoa’s Service.

2. Liability Limitations

• Your Insurer, mlcoa and medical specialist expert are not responsible for, and disclaim all liability, which may arise from any detriment to your/your child’s (as applicable) condition or any loss suffered from, the use of the Service.
• You release and indemnify your Insurer, mlcoa and medical specialist expert from all liability pertaining to this service, including the medical evaluation, the arrived diagnosis, treatment recommendations, and any/all consequential conditions, loss, damage, illness or injury impacts potentially arising as a result of using this service and or acting on the second opinion advice and recommendations provided.