Referrer Confidentiality Form

Complete your confidentiality form online or download PDF version

Download Privacy Form and complete or fill in this online form.


Use this form to setup an account for you as a referrer (eg GP, Specialist, Allied health etc) to access NCRG Radiology examination results and images. Your account request is checked by your Client Services Officer and set up for valid referrers. Training is available as part of the account set up process.

Privacy & Confidentiality Form

Referrer Details

(Name in full - firstname then lastname)

Practice Details

(eg Main Street Medical Centre or Dr Smith's Rooms)
(inc area code)

Privacy Sign Off

This practice, its staff, consultants and agents agree to comply with the Health Records & Information Protection Act 2002 and other relevant Privacy laws as well as the NCRG Privacy Policy. NCRG is requesting this information from you so we can provide our diagnostic imaging service and associated functions to you. For more information on our privacy obligation visit or speak with our Client Support Officer. When you tick Yes to agree the Policy below will disappear.

NCRG Privacy Policy

Images and reports from North Coast Radiology Group (NCRG), which includes North Coast Radiology, Clarence Valley Imaging, Chatswood Radiology and Ryde Radiology can be accessed by authorised users using Inteleviewer. There are three categories of authorised users
* NCRG staff have access to the patient information required to carry out their duties.
* Referring health service providers have access to the images and reports arising from their referral of their patient.
* Other registered medical practitioners and specialists involved in the treatment or care of the patient, where required for that treatment or care.

To become an authorised user, health service providers need to complete this form. If approved, NCRG will contact you once you have been set up on the system.

Application form
Privacy law requires that NCRG ensures that any access to its health records is restricted to authorised people and for justified medical diagnostic or treatment purposes only. NCRG also needs to protect its electronic systems and networks from viruses, other malware and unauthorised access.

Every individual who wishes to use Inteleviewer or PACS must sign this document, agreeing to comply with certain restrictions and to act in a way that maintains privacy for our patients, referrers and staff, and security of our information systems. You will also be agreeing to NCRG conducting regular audits of any or all episodes of external access to its PACS, for the purpose of monitoring compliance.

I hereby request access to NCRG's Inteleviewer and PACS. I agree to comply at all times with NCRG's rules related to the security and privacy of its electronic records. I will keep my user name and password absolutely confidential. I will act responsibly to maintain the security and integrity of the information systems that I use, so as to minimise the chance of any problems or security breaches for NCRG.

I will only look at my patients' medical imaging records for the purpose of providing diagnostic or treatment services to them and not for any other reason.

I will ensure that unauthorised people cannot gain access to confidential information. If I need to copy or print images or other information from the NCRG PACS, I will also treat them as confidential medical records. I agree to comply with any audit by NCRG or its agents of access to the NCRG PACS.

I understand that as a health service provider I am also bound by and subject to the provisions of the
Privacy Act 1988 (Cth), and the Health Records and Information Privacy Act 2002 (NSW).

Maximum file size: 20.48MB

Please use your mouse to sign this form