By submitting this referral form, I confirm that the patient (or their guardian or authorised representative, if under 18) has provided informed consent to:

• The collection, use and disclosure of their personal and health information for the purposes of coordinating care and assessing eligibility for services under Medicare Mental Health.
• Being contacted by the Medicare Mental Health team regarding this referral. This may include a phone call from (07) 3062 8437.
• Sharing relevant information with other health or support services involved in their care, including those nominated in this form (e.g. GP, family member, support worker).
• The secure handling of this referral, noting that submitted documents may be scanned by third-party antivirus software.
• Their anonymised information being shared with the Department of Health, Disability and Aged Care for reporting, evaluation and planning purposes. This may include non-identifiable details (e.g. date of birth, gender, types of services accessed), but not names, addresses, or Medicare card numbers.