Consent to release information form

As a patient under assessment with the New Zealand Familial Gastrointestinal Cancer Service, your family history assessor may ask you, or your relatives, to complete a consent to release information form. 

These consents allow us to confirm any reported cancers or relevant medical history in order to:

  • clarify your risk
  • give appropriate surveillance recommendations
  • offer advice as to whether any other investigations are appropriate.

We may require a consent to access information regarding yourself, a relative (to be signed by them) or a deceased relative (to be signed by their next-of-kin).

All information is treated as strictly confidential.

If you have been asked to fill out a consent to release information form, fill out the form below.

Make sure that your reference number is included on your form. This is found at the top of any correspondence from our service.

Information about the release of medical information

Why you are being asked for access to you medical information, or 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.

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 whānau.

The risks of providing the medical information

The risks of sharing the medical information are minimal.

Risks of providing your 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 whānau.

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 is requested

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

Where the medical information comes from

Depending on which organisation holds the records, NZFGCS may request information from hospitals, the NZ Cancer Registry, specialist, or a GP/doctor.

How will the information be used?

NZFGCS will use the information, along with the history of other members of your whānau 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 has access to the medical information

Access to your 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 whānau.

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 whānau.

How the privacy of the medical information will 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.

Call our office freephone line on 0800 554 555

We will arrange for the appropriate colleague to discuss this further with you prior to signing the consent form.

Consent form — release of medical information

This form is to be completed by the person listed above if living, or by their representative if deceased.

Medical information

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 whānau 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 whānau.

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.

Your information

Provide your details below (the person completing this form).