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.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

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: 16 July 2021