As part of providing a psychological service to you, Charles Lucas needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted.
Your personal information is gathered as part of your assessment and treatment and is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service to you. A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, which can be obtained by contacting Charles Lucas. The Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about our management of your personal information.
At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. Charles will discuss with you different possible forms of access.
All personal information gathered by Charles Lucas during the provision of the psychological service will remain confidential except when:
The cost of a consultation, usually around 50 minutes, is $150.00 which is payable at the end of the session. Medicare rebates are available if you have been referred by your GP and have a Mental Health Care Plan in place, and in these cases the rebate is $84.80 leaving a balance of $65.20. If payment is covered by a third party payer then the organisation will be billed separately. Charles Lucas uses Healthkit to manage the fees and this software, supported by the Federal Government, encrypts all information regarding credit card details so you can be assured of security in regard to this information and indeed, any other information you provide.
If, for some reason you need to cancel or postpone your appointment, please give at least 24 hours notice to enable Charles to activate the cancellation list or you may be charged the cost for the session.
Client Details
Given Name/s_____________________ Surname________________________
Mobile___________________________ Email___________________________
Address__________________________________________________________
Client Medicare Claiming Details
I request and authorise Healthkit Pty Ltd to enable online Medicare rebate claiming by registering and storing the following Medicare information.
Medicare Number: _______________________________________________________
Reference Number: _______ Valid to:_______/________
Date of Birth: _____/________/_________
Client Credit/Debit Card Authority
Name on Card _________________________________
Card Number___________________________________
Expiry Date ______/________
I request and authorise Healthkit Pty Ltd ABN:62131908597 to debit payments from the nominated credit card identified below in accordance with this payments authority, the Terms of Use and the Credit/Debit Card Authority Service Agreement. I authorise Healthkit to debit funds from my debit/credit card identified above when I have an appointment with or am provided services by Charles Lucas Psychologist. I acknowledge that Healthkit Pty Ltd will appear on my statement.
Signature
By signing this Payment Authority, I declare that the information contained is correct. I acknowledge that I have read and understood the terms and conditions contained in this payments authority and the Credit/Debit Card Service Agreement, and agree to be bound by them.
___________________________________________ Date ______/________/_______
Signature of the nominated Account/Credit Car