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ATAGI updated its advice on 29 April 2022. ATAGI now advises that when patients have had a confirmed COVID infection, COVID vaccination should be deferred for three months. This is to be entered into the Australian Immunisation Register (AIR) as a “temporary medical exemption” under the category “acute major medical illness”. The duration of the exemption should not be for more than four months.
ATAGI advises that either a positive PCR or RAT result should be used to confirm infection. You should be reasonably satisfied that the result is genuine and relates to your patient before issuing a certificate. RAT results should have been reported to the relevant reporting system where possible. You may wish to state in the vaccine exemption certificate that you are relying on the patient’s advice that they received a positive RAT result but have not independently confirmed it.
For further information:
ATAGI expanded guidance ATAGI Expanded Guidance on temporary medical exemptions for COVID-19 vaccines | Australian Government Department of Health
Clinical recommendations for COVID-19 vaccines | Australian Government Department of Health
Additional clinical considerations for COVID-19 vaccination | Australian Government Department of Health
AIR exemption form Australian Immunisation Register (AIR) - immunisation medical exemption form (IM011) | Services Australia
The ATAGI advice does not recognise a mental health condition as a medical contraindication to COVID-19 vaccination.
However, ATAGI has advised that if the potential recipient of a vaccine is a risk to themselves or others during the vaccination process, a temporary vaccination exemption may be appropriate. This is a matter for your clinical judgement.
In forming your clinical opinion, you should:
A number of patients are concerned about having the COVID-19 vaccination or about the steps that their employer is taking to mandate the vaccination. You will need to form a clinical opinion about whether concern about COVID-19 vaccination amounts to the patient being “a risk to themselves or others during the vaccination process”. In forming this opinion consider:
If you form a clinical opinion that it is appropriate to provide an exemption on the basis of a mental health condition, you should further note:
ATAGI expanded guidance ATAGI Expanded Guidance on temporary medical exemptions for COVID-19 vaccines | Australian Government Department of Health
AIR exemption form Australian Immunisation Register (AIR) - immunisation medical exemption form (IM011) | Services Australia
ATAGI has advised that influenza vaccines can be administered at the same time as the COVID-19 vaccine.
For more information see ATAGI advice on seasonal influenza vaccines in 2022 | Australian Government Department of Health
ATAGI advises that COVID-19 vaccines can also be co-administered with other vaccines. However, ATAGI has cautioned that there is currently limited evidence in relation to this, and that there is a potential for increased mild to moderate adverse events when two or more vaccines are co-administered. ATAGI therefore advises that vaccine providers should weigh up the opportunistic need for co-administration compared to giving the vaccines at different times.
Some key points:
In order to assess whether it is clinically appropriate to provide a medical certificate granting a COVID-19 vaccination exemption, we suggest you take the following steps.
Step 1: Take a patient history
You should first take the patient’s history, including the patient’s reasons for the request and the context in which they wish to use the certificate.
Step 2: Determine whether it is clinically appropriate to provide a certificate
In determining if it is clinically appropriate to provide a certificate, you should have regard to:
In addition, you should take into account:
Please note that it may be helpful for you to use a specific exemption form even if the form is not strictly required. It gives you and the patient clear guidance about clinical contraindications for vaccination and may be helpful in your discussions with the patient.
In practice, there are very limited circumstances where a patient would have a contraindication to every type of vaccine that may be available.
Step 3: Discuss the issues surrounding COVID-19 vaccines with your patient
Would you like further information?
Unfortunately, the answer to this question is complex.
Ahpra and the National Boards have provided guidance, which you can find at Facilitating access to care in a COVID-19 environment: Guidance for health practitioners
To help you navigate this issue and minimise the chances of running into a legal problem, we suggest you consider the following issues before you refuse to treat an unvaccinated patient.
Step 1: Check public health directions in your state and territory
Most state and territory public health directions do not currently prevent a patient from entering a medical practice if the patient is not vaccinated against COVID-19.
Step 2: Obligation to treat a patient
As general rule, a doctor does not have to treat a patient (even in an emergency) if there is a risk to the doctor’s health and safety or the health and safety of other patients under the doctor’s care (see clause 3.5 of Good medical practice: a code of conduct for doctors in Australia).
In NSW, the situation is slightly different because, under the Health Practitioner National Law (NSW), it is unsatisfactory professional conduct to refuse or fail to attend a person in need of urgent attention when requested to do so. The exception is when the practitioner has taken all reasonable steps to ensure that another medical practitioner attends instead within a reasonable time.
Step 3: Consider whether not treating a patient could be discrimination
You can refuse to treat an unvaccinated patient except when the patient is unvaccinated for a reason such as:
Even then, it can be lawful to discriminate to protect the health and safety of people in the practice.
In order to minimise the risk of a complaint, you should consider whether there is another way that the medical service can be provided to the patient (for example, via telehealth or in a part of the practice that other patients and staff cannot access).
Step 4: Consider work health and safety issues
Under the Medical Board’s code of conduct (see clause 3.4.5 of Good medical practice: a code of conduct for doctors in Australia), as a doctor, you have an obligation to keep yourself and your staff safe when caring for patients: “If a patient poses a risk to your health and safety, or that of your staff, take action to protect against that risk. Such a patient should not be denied care if reasonable steps can be taken to keep you and your staff safe.”
You also have obligations as a worker under work health and safety laws to ensure the health and safety of those at the practice.
The law says that you must undertake a risk assessment in consultation with the practice and practice staff to work out the risks associated with managing unvaccinated patients and what measures should be put in place to minimise or eliminate those risks.
Avant’s factsheet: Managing COVID-19 health and safety risks in medical practice explains the risk assessment process.
Step 5: Other factors
A patient might still make a complaint even if you are not discriminating against the patient and you have determined that you can only treat vaccinated patients for health and safety reasons.
Some things you can consider to minimise this risk include:
ATAGI has published clinical guidance on COVID vaccine administration errors, which can be found at ATAGI clinical guidance on COVID-19 vaccine administration errors | Australian Government Department of Health
If you wish to discuss any error after reading the ATAGI guidance, members can contact Avant’s Medico-Legal Advisory Service.
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You should always obtain consent when providing a vaccine.
However, it may be appropriate for a brief consent discussion to occur when patients have already had at least one dose, taking into account:
RANZCOG and ATAGI recommend that pregnant women are routinely offered the Pfizer or Moderna vaccine at any stage of pregnancy. They also advise that the Pfizer or Moderna vaccines are considered safe for those breastfeeding and their babies.
Ultimately, the decision about vaccination rests with the woman based on the available information and their personal circumstances.
For more information see:
Each parent has parental responsibility for their child so either parent can provide consent for vaccination, unless there is a parenting order.
A parenting order may be made by a court when parents are no longer together and can allocate responsibility for making decisions about major long-term issues about a child. A decision about vaccination is considered a major long-term issue.
If a parenting order gives sole parental authority to one parent, a decision to vaccinate a child can be made by that parent, subject to any terms in the order to consult with or notify the other parent.
If the parenting order gives sole parental responsibility to the parent requesting the vaccination and there are no terms requiring consultation with the other parent, it is reasonable to proceed with the vaccination based on the consent of that parent.
If a parenting order gives shared parental responsibility to both parents, a decision to vaccinate a child requires consultation between the parents, and the parents would need to make a genuine effort to come to a decision. If they cannot come to a decision, they need to make an application to the court to resolve their dispute.
There is no legal requirement for a doctor or medical practice to enquire and/or confirm that both parents have consulted about vaccination.
However, if there is a dispute between parents, and one parent makes it known they do not consent to the vaccination, where parents have shared parental responsibility or there are no parenting orders in place it is advisable to delay vaccination of the child until the parents have resolved their dispute over this issue.
The Family Court has put in place a process for parties seeking urgent orders in the COVID-19 List, including vaccination orders. For more information see Family Law Practice Direction – National COVID-19 List | Federal Circuit and Family Court of Australia (fcfcoa.gov.au)
For more information, please refer to our factsheet on Children and consent and our podcasts on medical records, treatment of children and separated parents.
COVID-19 vaccine information and consent form for parents and guardians of children aged 5 to 11 years | Australian Government Department of Health
A discussion of the risks and benefits of COVID-19 vaccination (and not vaccinating) for children should occur and be documented. Information provided to parents should reflect what is published by credible sources, including ATAGI.
It should be noted that the Pfizer vaccine can be given to children from age 5 years, and the Moderna vaccine from age 6 years.
ATAGI’s recommendations on Pfizer COVID-19 vaccine for use in children aged 5 to 11 years | Australian Government Department of Health
ATAGI recommendations on the use of Spikevax (Moderna) COVID-19 vaccine in children aged 6 to 11 years | Australian Government Department of Health
Children who have previously had COVID-19 infection can receive a vaccine following recovery from their illness or vaccination can be deferred for up to four months. ATAGI has confirmed this includes children with a past history of PIMS-TS or post COVID-19 condition (‘long COVID’).
ATAGI currently recommends the two doses of the Pfizer and Moderna vaccine be given to children eight weeks apart.
That interval can be shortened to a minimum of three weeks (Pfizer) or a minimum of four weeks (Moderna) in the following special circumstances:
ATAGI has recommended that the first dose is the child dose, and the second dose should be an adolescent/adult dose given eight weeks later.
At present, the TGA and ATAGI have not approved or recommended vaccination of children who have not turned 5.
The doses supplied by the Department of Health to vaccine providers are not to be used for this purpose.
It is mandatory for healthcare providers who administer the COVID-19 vaccine to a patient to record details of the vaccination in the AIR.
Patients can view their immunisation history on the AIR via their My Health Record or My Gov account or Medicare online.
As with any course of treatment, if your patient does not complete the course, you should explain the potential outcomes.
You cannot force your patient to have the second dose if they do not wish to have it. We recommend you document your advice and the patient’s decision in their medical record.
Article: Informed consent and communicating information
eLearning course (member only) Consent: informed consent and more
Factsheet: Consent essentials
Factsheet: Children and consent
Factsheet: Capacity essentials
Factsheet: Substitute decision makers
Podcasts: Separated parents – when parents disagree about a child’s treatment
These Medicare items are only available for participating practices.
Vaccinations must be bulk-billed for everyone living in Australia who is Medicare-eligible, including all Australian citizens, permanent residents, and most visa-holders.
Vaccine Suitability Assessment (VSA) Services
The Department of Health has released information about these 16 item numbers.
The services have to be billed in the name of the supervising GP, who must be present at the location at which the service is undertaken (including for the observation time).
The services can be undertaken face-to-face by a suitably qualified health professional. However, the supervising GP must accept full responsibility for the service.
The assessment cannot be done by telehealth.
A supply of the vaccine must be available for immediate administration. However, the item number should be billed if a patient declines the vaccine after the assessment has been performed.
If a patient undergoes a VSA and declines the vaccine at that visit but then returns to have the vaccine on another day, a second VSA can be billed when they return.
In-Depth Patient Assessments
The doctor must attend the patient in person, you cannot delegate this task to anyone else. Please note that you cannot undertake the assessment by telehealth.
Vaccine Booster Incentive
The Department of Health has released information about this item number.
It is to be claimed in conjunction with the appropriate Vaccine Suitability Assessment Service item when a patient receives a third or booster dose. It cannot be claimed for second doses.
Bulk-billing incentives (double for dose one, single for dose two) will be incorporated into the value of the items and will not need to be claimed separately ($10 per dose).
The double payment of the bulk-billing incentive for the first dose is in recognition that some patients will need longer explanations about the vaccine than others.
Where both doses have been provided to the patient by the practice, the practice will be eligible for a PIP incentive of $10 (per patient) on completion of the second dose.
No, it is not permissible under Medicare rules to charge a fee or co-payment for a service that is bulk-billed.
The Department of Health has advised general attendance items cannot be used to triage or screen patients before booking or performing a Vaccine Suitability Assessment.
This means that, for patients who are making bookings to have the vaccine, you cannot routinely book and charge them for a general attendance item first.
You cannot charge any “new patient fee” or similar.
Doctors and practices have been required to refund fees to patients and have been removed from participating in the vaccination rollout, when they have not complied with this.
You can only do this if your patient requires a service unrelated to the vaccine. You cannot claim any item other than a VSA, In-depth Assessment, Flag-fall or Vaccine Incentive Booster for the administration of the vaccine.
The Department of Health prefers that patients presenting with multiple clinical matters be encouraged to book a separate consultation, and preferably with their usual practice. However, there may be some circumstances where deferring treatment is not feasible or in the patient’s best interests. In these situations, standard MBS multiple same-day attendance rules apply.
Your medical record will be important to demonstrate that this is a separate service. We recommend you make detailed notes about each service. The Department of Health recommends that you state: “The additional service [MBS item…] is clinically relevant but not related to the vaccine suitability assessment service [MBS item…].”
The practice must obtain and document the patient’s informed financial consent to ensure that the patient understands there is no cost associated with the COVID-19 vaccine. You must inform patients if any other service that they receive on the same occasion will be bulk-billed or subject to a patient co-payment.
The Department of Health has stated that the COVID-19 vaccination MBS items have been exempted from the 80/20 rule.
Any general attendance items billed where COVID-19 vaccinations are discussed will still be included in the 80/20 rule.
You can claim other Medicare items numbers when a patient suffers a significant adverse reaction to a vaccine to allow you to provide appropriate treatment.
The Department of Health has confirmed that in situations where doctors at participating practices have a discussion with a patient in relation to their suitability for the vaccine and the vaccine is not available to be given immediately, you can bill general attendance Medicare items.
These general attendances do NOT need to be bulk-billed.
For example, a patient books a normal visit with you and when they arrive they only wish to discuss the vaccine and their suitability, but you do not have a vaccine dose available for them at that time.
All general attendance items will be subject to the 80/20 rule.
However, the Department of Health has advised general attendance items cannot be used to triage or screen patients before booking or performing a Vaccine Suitability Assessment. This means that you cannot routinely book and charge patients who are making bookings to have the vaccine for a general attendance item first. You cannot charge any “new patient fee” or similar.
In circumstances where it is unforeseen that a vaccine is unavailable to be given when a patient attends for a vaccine suitability assessment, the Department of Health has advised that the VSA can be billed at the time and another one can be billed when the patient returns for the vaccine. For example, you may experience a delay due to an unanticipated staff absence. However, valid reasons do NOT include inadequate staff rostering or when there is insufficient supply of vaccine doses.
Yes, however, you cannot charge for this, either to Medicare or by private billing.
You are not expected to provide this service as part of any agreement with the Department of Health.
You may choose to refer patients who are not Medicare-eligible to a state-based vaccine delivery site, to a Commonwealth Vaccination Clinic (previously known as a General Practitioner-led Respiratory Clinic) or to another other clinic as advised by the Department of Health if these facilities are not available. They will not be charged at these clinics.
Doctors at non-participating practices can bill general attendance items for discussions relating to the vaccines. These do not need to be bulk-billed.
Non-participating practices are not able to bill Vaccine Suitability Assessments, In-depth Patient Assessments or Flag-Falls.
The Department of Health has advised that action will be taken for any use of Medicare items that is not in accordance with guidelines and legislation.
In addition to usual Medicare compliance, doctors and practices are being contacted by the National COVID Vaccine Taskforce when complaints have been made about their billing. In some cases, doctors and practices are being required to undertake extensive audits, and to repay considerable amounts to patients or Medicare.
The Taskforce states it may revoke a practice’s participation in the vaccine rollout if necessary.
We recommend that you contact Avant for advice if you are contacted by the National COVID Vaccine Taskforce or Medicare.
Many practices have asked us whether an unvaccinated healthcare worker with a vaccine exemption can attend work. We suggest the following process when considering this request.
Step 1: Consider the current public health direction
All jurisdictions have a public health direction which requires healthcare workers to be vaccinated in order to attend work. The terms of the public health direction vary between jurisdictions.
In most jurisdictions, the public health direction allows an unvaccinated healthcare worker to attend work if they are unable to be vaccinated due to a medical contraindication.
There are two parts to this test:
In some jurisdictions, the public health direction also has specific requirements about a healthcare worker attending work (such as a requirement for the practice to undertake a risk assessment or regular COVID-19 tests, or to wear particular PPE).
Step 2: Seek information about the healthcare worker’s medical contraindication
The practice may need information about the nature of the healthcare worker’s medical contraindication in order to consider whether and for how long the healthcare worker is unable to be vaccinated, and to undertake a risk assessment.
It will generally be reasonable to require a healthcare worker to provide information about their medical contraindication for these purposes.
In some cases, the reason relied upon in an exemption certificate may not amount to a medical contraindication which prevents the person from being vaccinated. For example, ATAGI has confirmed there is not a medical contraindication to vaccination where a person has had a COVID-19 infection and recovered from the acute illness (see our related FAQ here).
The practice should ensure that it does not inadvertently discriminate against a healthcare worker based on the healthcare workers’ disability. Any control measures or decision about attendance at work should be based on objective criteria and should be confirmed in writing.
Step 3: Practice risk assessment
Work health and safety legislation requires the practice to ensure the health and safety of the healthcare worker and other persons at the practice as far as reasonably practicable. This obligation continues even if a public health direction permits an unvaccinated healthcare worker to attend the workplace.
The practice should conduct a risk assessment to consider the risks of an unvaccinated healthcare worker attending the practice. You can find further information in our factsheet at Avant - Managing COVID-19 health and safety risks in medical practice.
That risk assessment may conclude:
Ahpra and the National Boards have provided guidance which you can find at Facilitating access to care in a COVID-19 environment: Guidance for health practitioners.
To help you navigate this issue and minimise the chances of running into a legal problem, we suggest you consider the following issues before you refuse entry to an unvaccinated patient.
Step 1: Check the public health directions in your state and territory
State and territory public health directions do not currently prevent a patient from entering a medical practice if the patient is not vaccinated against COVID-19.
In NSW, the situation is slightly different because under the Health Practitioner National Law (NSW) it is unsatisfactory professional conduct to refuse or fail to attend a person in need of urgent attention when requested to do so. The exception is when the practitioner has taken all reasonable steps to ensure that another medical practitioner attends instead within a reasonable time.
Step 3: Consider whether the decision not to treat the patient may be discriminatory
You can refuse to allow an unvaccinated patient to enter your practice except when the patient is not vaccinated for a reason such as:
It can be lawful to discriminate if it is necessary to ensure the health and safety of people in the practice.
However, the practice should first consider whether there is another way to provide a service to the patient other than through entry to the practice (for example, via telehealth or with staff dressed in full PPE).
Under work health and safety laws, practices must ensure the health and safety of their workers, patients and others at the workplace.
Your practice should undertake a risk assessment in consultation with practice staff to determine whether patient vaccination against COVID-19 is necessary to ensure health and safety in the workplace. Avant’s fact sheet: Managing COVID-19 health and safety risks in medical practice explains the risk assessment process.
Your practice should already have policies in place for dealing with:
Your practice may wish to consider other factors before making a decision to refuse treatment to an unvaccinated patient:
The patient is responsible for making an appointment for any subsequent doses of the vaccine.
If a patient does not book subsequent appointments at the same time, we suggest that you remind them at their visit to make the appointments for subsequent doses and offer to make that appointment at the clinic.
If the patient does not attend the practice for subsequent vaccinations, the practice could send an SMS reminder assuming consent has been provided to communicate via SMS.
Otherwise, we suggest you follow your usual follow-up protocol to recall patients for their subsequent doses.
Yes. The Department of Health has confirmed that all authorised immunisation providers must have completed the free COVID-19 vaccine specific training to administer the vaccines.
Non-clinical training modules are also required to be completed by non-clinical and administration staff who are involved in vaccine handling, storage and administrative reporting.
There are frequent updates to the content in the training program. You must review these whenever you are advised they are available.
Everyone involved in the administration (including doctors who have the responsibility for supervision) of specific brands of vaccines, must complete the modules specific to those brands.
There are also separate mandatory modules for administration of Pfizer and Moderna to children, which must be completed by all who are involved in the administration of those brands to children.
Public health directions in each state and territory require all staff working in a private sector medical practice to have a first and second dose of a COVID-19 vaccination unless an exemption applies Public health directions may require a booster or third dose, so ensure you check the current directions in your state or territory.
Public health directions or public sector policy in each state and territory require all staff working in public sector healthcare to have a first and second dose of a COVID-19 vaccination unless an exemption applies. Public health directions or public sector policy may require a booster or third dose, so ensure you check the current directions or policy in your state or territory.
You must comply with the Medical Board’s Social media: How to meet your obligations under the National Law and COVID-19 vaccination position statement when you publish information on your social media accounts. Ahpra issued a statement about the use of social media during public debate about the COVID-19 vaccine.
You should ensure your social media use complies with your employer’s policies.
Disciplinary action may be taken against doctors who contravene an employer’s social media policies.
Please refer to Avant’s factsheet: Social media for doctors – keeping it professional.
We also suggest you review the Therapeutic Goods Administration’s guidance about advertising COVID-19 vaccinations.