Practice Incentives Program Indigenous Health Incentive patient withdrawal of consent form (IP029)

Use this form to withdraw your consent to participate in the Practice Incentives Program (PIP) Indigenous Health Incentive (IHI).

Download and complete the Practice Incentives Program Indigenous Health Incentive patient withdrawal of consent form.

This form needs to be completed and signed by the patient withdrawing their consent from the PIP IHI.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 28 July 2022