Signing example
Sign a patient privacy consent online
A patient privacy consent has to record exactly which kinds of sharing the patient agreed to and which they refused, in a form every doctor in the practice can read the same way. In this two page consent the patient marks three of four sharing choices, leaves the fourth empty, types her nominated GP, and signs.
The document, with its fields
The pages as a signer sees them, with the signature, name, title and date fields placed where each party has to complete them.
Patient Privacy and Information Sharing Consent
| Patient | Rosalind Achebe, date of birth 4 April 1969, patient number SMG-77104 |
|---|---|
| Practice | Saltwater Medical Group, a group general practice with six doctors, two practice nurses and a visiting dietitian |
1. What this form is for
Your health information is collected so we can care for you. Some of it is shared as a normal part of that care, such as a referral letter to a specialist you have agreed to see, or a pathology request. Other sharing is your choice. This form records those choices so every doctor and nurse here, and anyone covering for them, follows them. You can change any choice at any time by telling reception or your doctor, and we will ask you to sign an updated form.
2. Your sharing choices
Type an X in the box beside each kind of sharing you agree to. An X means yes. An empty box means no, and we will not share in that way. Saying no does not affect the care you receive here.
| Yes | Choice |
|---|---|
| My nominated GP. Send a summary of each visit to the GP I name below, when I see a doctor here who is not my usual GP. | |
| My Health Record. Upload a shared health summary and event summaries to my national My Health Record. | |
| Family member. Discuss my test results and appointments with my husband, Emeka Achebe, if he phones on my behalf. | |
| Reminders by text. Send appointment and screening reminders to my mobile by text message. |
3. Your nominated GP
If you usually see a GP outside this practice, or a particular doctor here, type their name and practice so visit summaries go to the right person.
4. Sharing that does not need your choice
Some sharing happens without asking you each time, because it is part of the care you came for or because the law requires it. We share:
- with specialists, hospitals and allied health professionals you have agreed to be referred to;
- with pathology and imaging providers carrying out tests your doctor orders for you;
- with Medicare and your private health fund to process claims you make;
- where the law requires, such as notifying certain infectious diseases to NSW Health, or under a court order;
- where there is a serious threat to your life, health or safety, or someone else's, and it is not practical to ask you.
5. Opting out of research and teaching
We do not use identifiable patient information for research. De-identified information may be used to check the quality of our care, for example how many patients with diabetes have had a recent eye check. Medical students sometimes sit in on consultations; your doctor will always ask you first, and you may say no.
6. How long we keep records
Adult records are kept for at least seven years after your last visit, as NSW law requires, then destroyed securely. They are stored in an encrypted clinical system that only our staff can access, each with their own login.
7. Seeing your record
You may ask to see or get a copy of your record. We respond within 30 days. If you think something in it is wrong, you may ask us to correct it. Questions or complaints about privacy go to our privacy officer, the practice manager, on 02 4926 1180. If you are not satisfied, you may contact the Office of the Australian Information Commissioner.
8. Your consent
I have read this form and the practice's privacy policy. The choices I have marked on page 1 are mine, and I understand I can change them at any time.
Who signs what
- Rosalind Achebe, patient
- Four sharing choices on page 1, an X for each one she agrees to · Nominated GP and practice, typed · Signature, stamped date and name on page 2 · Email link
The signing journey
Step 1
Eight fields for one patient
Four optional checkboxes and a text field on page 1, then a signature, a date and a name on page 2.
Step 2
Optional boxes make no a real answer
Each checkbox has Required switched off, so leaving one empty is allowed and, as the page says, means the practice will not share in that way.
Step 3
Three yes, one no
She types an X for her nominated GP, My Health Record and text reminders, and leaves the box about discussing results with her husband empty.
Step 4
Her GP in her words
She types Dr Ines Varga, Merewether Family Practice on the ruled line, then signs page 2. Her name fills from the recipient record and the date is stamped.
Every field, and who fills it
Rosalind Achebe is the only signer. In the Yes column on page 1 she types an X beside My nominated GP, My Health Record and Reminders by text, and leaves Family member empty. On the ruled line under section 3 she types her nominated GP. On page 2 she draws her signature, her date is stamped and her full name fills from her recipient record. The practice's address, the form number and every statement are printed in the PDF.
How to adapt this envelope
A specialist practice can replace the GP line with a referring doctor line and keep the same four box pattern for its own sharing choices. A practice that treats children adds a parent as the signer and a line for the child's name. When the form is revised, send the new version as a new envelope; the certificate of the old one still shows what the patient agreed to at the time.
Why the record matters
Privacy choices are tested when something is shared, and the question is whether the patient agreed. The certified PDF shows the boxes exactly as she left them and cannot be edited afterwards. In Australia, the Electronic Transactions Act 1999 recognises her electronic signature, and the Office of the Australian Information Commissioner explains how health information may be used and disclosed.
What makes this signing flow work
An empty box is a recorded refusal
The family member box is empty on the signed page, and the form says an empty box means no. Because the field was optional, that empty box is a choice she made, not a field she skipped past.
Choices on page 1, signature on page 2
The choices are on the first page so they are read first, and the explanation of sharing that needs no consent comes before the signature. The consent paragraph then refers back to the choices she marked on page 1.
Two version numbers, two different things
The form carries its own version, PC-2026.2, printed in the header. The certificate separately records the version of the electronic signing consent she accepted. Together they show which privacy form and which signing terms she agreed to.
Questions people ask
Can a patient change their sharing choices later?
Yes, at any time, by telling reception or their doctor. The signed PDF cannot be edited, so the practice sends an updated form as a new envelope and the patient signs again. Both certified copies are kept, so the record shows what applied and when.
Why is the family member box empty on the signed form?
Because she chose not to allow it. The checkbox was optional, so she could finish without filling it, and the form states that an empty box means no. The practice will not discuss her results with her husband if he phones.
What is the consent version on the certificate?
It is the version of the electronic signing consent she accepted in the signing portal, recorded with the time she accepted it. It is not the version of the practice's privacy form, which is printed on the form itself as PC-2026.2.
Does the patient need an account to sign?
No. She opens the link in her email, reads both pages, types her choices and her GP, draws her signature and accepts the electronic signing consent. The certified copy is emailed to her and to the practice once she finishes.
Can the practice fill in the nominated GP for the patient?
No. The editor has no way for the sender to type a value into a field, so the GP's name and practice are typed by the patient. That keeps the nomination in her own words, which is the purpose of asking.
What if the patient declines to sign the privacy consent?
The envelope moves to declined and the practice is emailed with any reason typed. Her care continues, and the sharing that needs no consent, such as referrals she has agreed to, still happens. Optional sharing does not, until a consent is signed.
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