Scope of Practice Acknowledgement:
I,(“Patient”) understand and acknowledge the following:
• Staff employed by TeleSleep are not medical doctors, nor are they my individual medical doctor. I acknowledge that advice regarding medical conditions and treatment not relating to provision of CPAP should be discussed with my primary care provider as necessary or when advised by TeleSleep staff.
Consent for Disclosure and Transfer of Personal Information
I, (“Patient”) consent to “TeleSleep” ABN 63 452 144 699 (“Provider”) disclosing and transferring my Personal Information described below to the relevant Supplier as indicated below.
• Philips Electronics Australia Ltd ACN 008 445 743, a Philips company (“Philips”) with its principal office at 65 Epping Road, North Ryde, New South Wales, 2113 and to Philip’s Affiliate Companies for the purposes described below.
• ResMed Asia Pacific Limited ABN 86 070 076 470 (“ResMed”) of 1 Elizabeth Macarthur Drive, Bella Vista, New South Wales, 2153 and to ResMed’s Affiliate Companies for the purposes described below.
• Fisher & Paykel Healthcare Limited ABN 52 005 484 999 (“Fisher & Paykel”, “F&P”) of 19-31 King St, Nunawading, Victoria 3131 and to Fisher & Paykel’s Affiliate Companies for the purposes described below.
A reference to the Philips, ResMed or Fisher & Paykel (“Supplier”) in this form includes a reference to Affiliate Companies. Affiliate Companies means any company or other entity which controls the Supplier, is controlled by the Supplier, is under common control with Supplier or is otherwise related to Supplier.
My Personal Information to be disclosed to the Supplier directly by Provider is as follows: my name, date of birth, gender and my contact information; name and contact information for my Provider; my physician and/or sleep testing facility; name and device serial number of my therapy device and accessories used with my therapy device; notes related to my treatment and related to interactions with me from my Provider, sleep lab and/or physician; and my answers to questionnaires.
I further consent to the transfer of my Personal Information described as follows:
to Supplier by way of electronic upload from my Smart Card or from a modem in connection with my use of the therapy device provided to me by my Provider: my usage information, including start and end time of therapy each day; therapy statistics such as apnea Index, hypopnea index, apnea-hypopnea Index; leak; and pressure; and
to Supplier in connection with my use of Care Orchestrator (Philips), MyAir (ResMed) or InfoSmart (Fisher & Paykel): my usage information, including start and end time of therapy each day; therapy statistics such as apnea Index, hypopnea index, apnea-hypopnea Index; leak; and pressure.
All of my Personal Information described above is transferred to the Supplier for the following purposes: provision of healthcare services to me and monitoring of my therapy by Provider, my physician and sleep testing facility personnel.
I understand that:
Other than the Provider and Supplier and a limited number of authorised personnel of the Provider and Supplier, only my physician and/or sleep testing facility personnel will have access to my Personal Information held by Supplier. Authorised Provider and Supplier personnel have access to my Personal Information only for purposes of maintenance and support. To facilitate the provision of healthcare services considered above, Supplier may disclose Personal Information to the following third parties: its related bodies corporate; suppliers and service providers; IT outsourcing providers located in the USA or elsewhere; businesses that it buys or transfers; to its agents, lawyers and other professional advisors; government agencies and law enforcement agencies when required by a law or a court order.
Supplier will hold my personal information on secure computer systems in the USA and will take reasonable steps to protect all of my Personal Information that it holds from misuse, loss and unauthorised access, modification or disclosure in accordance with Australian privacy laws relating to personal health information.
Provider and Supplier may de-identify my Personal Information and use certain de-identified information. De-identified information does not contain any information that may identify me or any other individual. Provider will provide an informed consent document for my consideration if seeking my permission to use my de-identified information for the purposes of study or research.
I am not under an obligation to consent to the transfer of my Personal Information. However, without this information, my physician may not be able to provide me with an appropriate level of service.
Philips’s Privacy Policy, available at http://www.philips.com.au/
If I have any questions or wish to gain access to any of my Personal Information, I may contact the Provider or Supplier. I have read and understood this Consent and I agree to the terms of this Consent for disclosure and transfer of my Personal Information to Supplier.
Client Code of Conduct
As a TeleSleep Client, I agree to engage in reasonable conduct when communicating with TeleSleep, it’s representatives, and other TeleSleep Clients.
Unreasonable behaviour is conduct that is unreasonable in all circumstances – regardless of how stressed, angry or frustrated that a client is – because it unreasonably compromises the health, safety and security of our staff, other service users or the client themselves.
Some examples of unreasonable behaviours include (not exhaustive):
• Acts of aggression, verbal abuse and derogatory, racist, or grossly defamatory remarks
• Harassment, intimidation or physical violence
• Rude, confronting and/or threatening face to face or phone contact or correspondence
• Threats of harm to self or third parties, threats with a weapon or threats to damage property including bomb threats
• Stalking (in person or online)
• Emotional manipulation.
TeleSleep has a zero tolerance policy towards any harm, abuse or threats directed towards staff or other Clients. Any conduct of this kind will be dealt with under this policy, the Unreasonable Conduct by Customers Policy
• Incidents will generally be managed by limiting or adapting the ways that we interact with and/or deliver services to customers by restricting:
Who they have contact with
What they can raise with us
When they can have contact
How they can make contact
Terminating our services altogether
When using the restrictions provided in this section TeleSleep recognises that discretion will need to be used to adapt them to suit a Client’s personal circumstances, level of competency, literacy skills, etc. In this regard, we also recognise that more than one strategy may need to be used in individual cases to ensure their appropriateness and efficacy.
