Consent to share information
Purpose: to record freely given informed consumer consent to share their information with a specific agency/ies for a specific purpose/s.		Consumer
Name:      
Date of Birth: dd/mm/yyyy      /      /    
Sex:      
UR Number:      
or affix label here	
Section 1: Personal/health information to be shared 
Service Type
Examples:
– physiotherapy
– counseling
	Name of Agency
Examples:
–	Strawberry Community 
Health centre
–	Blueberry City Council	Type of Information
Examples:
– all relevant 	information
– exceptions as stated 	by consumer	Purpose/s
Examples:
– referral
– shared care/case planning
-- informing services participating in 	consumer’s care	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
Section 2: Record of consent
 Written consumer consent 
The worker/practitioner has discussed with me how and why certain information about me may be shared with other service providers, as above. I understand this and I give my consent for the information to be shared.
Signed:	
Dated (dd/mm/yyyy):     /      /    
or
 Verbal consumer consent 
I have discussed with the consumer how and why certain information may be shared with other service providers. I am satisfied that this has been understood and that informed consent for the information to be shared as detailed above has been given.
or
 Consumer does not have the capacity to provide consent
(that is, they do not understand the nature of what they are consenting to, or the consequences)
	 Consent given by authorised representative      	
                                                                                                              (name of authorised representative)
	 There is no Authorising representative or they were uncontactable; therefore, the information will be shared as 		set out in the Health Records Act 2001*
*If it is not reasonably practical to obtain consent from an authorised representative or the consumer does not have an authorised representative, health information can still be shared in the circumstances set out in the Health Records Act 2001. This includes where the sharing of information is done by a health service provider and is reasonably necessary for the provision of a health service or where there is a statutory requirement.	
To ensure that the consumer’s authorised representative can make an informed decision about consenting to the sharing of information as detailed above, the worker/practitioner should (tick when completed):
1.	Discuss with the consumer the proposed sharing of information with other services/agencies	
2.	Explain that the consumer’s information will only be shared with these services/agencies if the consumer has agreed	
	and, when referring, advise that referral for service can still proceed if the consumer does not want information disclosed	
3.	Provide the consumer with information about privacy, such as the brochure Your Information – It’s Private	

Consent to Share Information

4.		Provide the consumer with a copy of this form once completed.	
		Produced by the Victorian Department of Health, 2012	
Consent obtained/witnessed by:	CSI Page 1 of 1	
Name:      	Position/Agency:      	
Sign:	Date: dd/mm/yyyy        /        /    	Contact number: