NZFGCS > Patients > Patient Consent Form

INFORMATION SHEET: RELEASE OF MEDICAL INFORMATION

Why am I being asked for access to my medical information / a deceased person’s medical information?
You are being asked for access to the medical information so that the New Zealand Familial Gastrointestinal Cancer Service (NZFGCS) may better understand the patterns of cancer/bowel polyps in your family by confirming the cancer history. This will provide information to you/your family about appropriate surveillance.

What are the benefits of providing the medical information?
Understanding your medical history or the deceased person’s medical history will enable us to give specific advice to, and make recommendations for, you and your family/whanau.

What are the risks of providing the medical information?
The risks of sharing the medical information are minimal.
Risks of providing my information: NZFGCS does not share your specific information with any person other than your GP and your referrer and will only share a general summary with members of your family/whanau.
Risks of providing deceased person’s information: NZFGCS will not identify who had the cancer and will only share a general summary with members of your family/whanau.

What medical information will be requested?
Only the medical records related to your history or the deceased person’s history of cancer/polyps/genetic testing will be requested.

From where will the information be requested?
Depending on which organisation holds the records, NZFGCS may request information from hospitals, the NZ Cancer Registry, specialist, or General Practitioner (GP)/doctor.

How will the information be used?
NZFGCS will use the information, along with the history of other members of your family/whanau who have been affected by bowel polyps or cancer, to build a picture to assess whether there may be a genetic disorder in the family.

Who will have access to the medical information?
Access to my information: Only NZFGCS staff will have direct access to the medical information. Your information will be shared with your GP and other health professionals involved in your care. A general summary of your medical information may be shared with other members of your family/whanau.
Access to the deceased person’s information: Only NZFGCS staff will have direct access to the medical information. A general summary of the deceased person’s medical information may be shared with other members of his/her family/whanau.

How will the privacy of the medical information be protected?
The medical information will be stored securely. The data will be stored in a password-protected data system and the file will be stored in secure conditions. Where the data is used for national reporting, you/your relative will not be able to be identified by name or NHI number in keeping with usual healthcare practice.

Will the medical information be used in research?
NZFGCS undertakes clinical audits and, from time to time, NZFGCS contributes data to international gastrointestinal cancer research projects which have been approved by ethics committees. The information may be used for each of these. However, the data will be de-identified. This means that neither you/the deceased person, nor your family/whanau, will be able to be identified by name or by NHI number.

I have further question(s) and/or do not understand the above information?
Please call our office freephone line (details at the top of this page) so we can arrange for the appropriate colleague to discuss this further with you prior to signing the consent form.
CONSENT FORM: RELEASE OF MEDICAL INFORMATION
Consent required for: *
NZFGCS Reference number (if known)
^$|^([a-zA-Z])([0-9]{6})$
Form to be completed by the person listed above if living or by their representative if deceased.
Date of birth
If deceased, date of death
NHI (If known)
^$|^([a-zA-Z]{3})([0-9]{4})$
GP Name/ Practice

Matrix

Blank	Year of Diagnosis	Cancer/Polyp Diagnosis (eg. bowel cancer; bowel polyps)	Hospital Name and City	Name of Specialist (if known)
1
2
3
4

Declaration

1. I understand that:
a. The New Zealand Familial Gastrointestinal Cancer Service (NZFGCS) requests access to the above medical information.

b. The information requested is related to the medical history of bowel polyps and/or cancer and/or genetic testing.

c. Information will be used by NZFGCS to assess the risk to me and my family/whanau of gastrointestinal cancer syndromes and that this is not research.

d. The information will be stored securely.

e. A general summary of the medical information may be shared with members of my family/whanau.

f. De-identified data may be used for clinical audit or for a research project approved by an ethics committee.
2. I fully understand the information sheet on the top of this page and have been given the opportunity to ask questions related to this consent, and my questions have been answered to my satisfaction.
3. I give my informed consent for NZFGCS to access the above medical records for the stated purpose.
Agreement

I have read and agree to the above declaration.
Please provide your details below (individual completing this form)
First Name
Last Name
Address
Email
Day Time Phone Number
Relationship to deceased person (if completing the form on behalf of a deceased person)
Date of birth (if completing the form on behalf of a deceased person)

CONSENT FORM: RELEASE OF MEDICAL INFORMATION

Declaration