Consent to Obtain and Share Information form Please enable JavaScript in your browser to complete this form.Consent to Obtain and Share Information **Required prior to Akadia Community Care commencing any services** Purpose: to record freely given informed consumer consent to share their information with a specific agency/ies for a specific purpose/s.Email *EmailConfirm EmailPlease add authorised representative email hereI (authorised representative) give consent for Akadia to access, collect and share information on the NDIS participantAuthorised Representative *FirstLastPlease add the first and last name of the authorised representativeParticipants full name *FirstLastPlease add the first and last name of the participantNDIS number *For the purpose of assessing and developing care management in accordance with the NDIS Plan of the Participant.This consent will remain valid for 12 months from the date of signing and can be altered or withdrawn at any time by written consent of the signing authority below. I authorise the sharing of information relating to my medical requirements (or the Participant I am representing) between Akadia Community Care and the following: *Medical Practitioners eg. GP, specialists etc.HospitalGovernment AgenciesNDISSupport CoordinatorOtherOtherPlease add hereAkadia will not share your personal information to anyone unless you have given your permission or the disclosure of your information is required or authorised by law. By signing this form I understand that I hereby confirm consent and acknowledge the following: I acknowledge that I am aware of my rights to access my personal information I acknowledge my right to amend or withdraw my consent at any time I understand that Akadia must comply with the Privacy Act 1988 and all relevant privacy laws I understand why certain information about me may be needed to be accessed for the provider to assess and develop the best care plan for me Authorised Representative *FirstLastPlease add the first and last name of the authorised representativeRelationship to participant *Date *Signature *Authorised Representative please sign hereSubmit (07) 4659 5662 Street Address 18 Hanna Ct,Kearneys SpringQLD 4350 Postal Address PO Box 8209, Toowoomba, QLD 4350 FollowFollow
