Consent to communicate with a service provider and/or organisation

Consent to communicate with an Organisation or Service Provider

Your privacy is very important to us. We will only share information and communicate with an organisation or service provider about your care needs where you have given us consent to do so.

Use this form to give consent for MND NSW to communicate with your health and community care providers. This may include your doctor, neurologist, occupational therapist, physiotherapist, speech pathologist, NDIS coordinator of support or any other professional or organisation involved in your care.

You may choose to provide consent for one or more unnamed professionals from the same organisation.

At any time, you can change, update or withdraw your consent by contacting us on 1800 777 175 or email infoline@mndnsw.org.au. You can view our privacy policy here or ask for a copy to be posted to you.

Questions marked * will require an answer.

About the Organisation or Individual Service Provider I am Authorising

Is this Consent for an Organisation/Service or an individual practitoner?*

Consent is for an Organisation/Service named on this form.

Consent is only for the individual practitioner/worker named on this form.

Please select

Organisation/Service type

Invalid Input

First Name (if individual)*

Please enter the first name of the person MND NSW may communicate with

Last Name (if individual)*

Please enter the last name of the person MND NSW may communicate with

This person is my

Please choose

If Other, please type relationship name

Invalid Input

Contact details for the Organisation or the Individual Service Provider I have nominated above

Workplace/Organisation Name*

Please enter Workplace/Organisation name (if Consent is for an individual, this is their workplace; if Consent is for an Organisation, this the name of the Organisation)

Street

Please enter letters and numbers only

Suburb/Town

Please type only Letters

Postcode

Please only type numbers

Email (Work)

Invalid email address.

Phone (Work)

Please type numbers

Phone (Mobile)

Please type numbers

Your details (the Participant)

Title*

Invalid Input

First Name*

Please type your First Name

Last Name*

Please type your Last Name

Date of Birth*

Please enter your Date of Birth

Suburb/Town*

Please type your Suburb/Town

Postcode*

Please type your Postcode

Home Phone

Please type numbers

Mobile

Please type numbers

Email*

Invalid email address.

Details

Name of person completing form if not Participant

If you are completing the form to assist the participant, please type your name here.

Security*

Invalid Input

Consent to communicate with a service provider and/or organisation

Consent to communicate with an Organisation or Service Provider

About the Organisation or Individual Service Provider I am Authorising

Your Consent

Your details (the Participant)

Details