NGĀTI HINE HEALTH TRUST

I understand that the information that I give will be held at the offices of He Waka Tapu only for the purposes intended and that my permission is required to transfer this information to another person/organisation not directly involved in my care (except in cases of exception as detailed below). I am aware of the rights of access to and correction of this information.

I understand that providing this information is voluntary and doing so will help He Waka Tapu provide an effective, efficient service. I understand that my information may be passed on to other clinical staff involved in providing and administering health care and treatment, whether an employee of He Waka Tapu or another provider providing related services to you. I understand that this information will be used for the following;

• To assist with administration,
• Training and education
• Monitoring quality of patient care, treatment and health outcomes
• Statistical analysis conducted by the Ministry of Health and/or planning and funding purposes with the CDHB (non- identifying information)

I give consent for my personal records to be accessed by relevant clinical staff at He Waka Tapu.

I agree to the consent for collection and release of information as provided above.

I have had the services at He Waka Tapu explained to me and i have had an opportunity to ask questions.

As a part of this referral, I understand and agree that I will need to release various documents and/or reports to He Waka Tapu for the purpose of assessing whether the specific program requested is appropriate for me.

I understand that He Waka Tapu follows a Tikanga Maori based framework in addressing issues of alcohol and drug abuse, family violence and criminal offending and I agree o fully participate in this process.

I give consent for the Registered Nurse at He Waka Tapu to request information regarding my health or medical information with Allied Health Professionals. I also understand that my personal information will be held in privacy and with absolute confidentiality.

I acknowledge that my referral will take up to (10) working days to process after which time I will be contacted with a decision either to accept or decline it.

Exceptions for disclosure of personal information

I understand that He Waka Tapu will not disclose my information to any other provider/agency unless my authorisation is given or unless required by legislation. Situations where disclosure of my information may apply;

• Any Funder information request, specifying the part of their legislation applicable or
• Child, Youth and Family information request, specifying the part of their legislation applicable.

Parent/Guardian Consent: (if young person is under 16)

I give consent to the participation of my child in any He Waka Tapu Youth Program. I have read and understand the terms outlined in this consent form.