enrol

Practice Enrolment Application

I am entitled to enrol because I am residing permanently in New Zealand. (The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months)

Enrol
Enrol with Clinic?

NAME

BIRTH DETAILS

OCCUPATION

USUAL RESIDENTIAL ADDRESS

POSTAL ADDRESS

Address *
Address
City
State/Province
Zip/Postal
Country

CONTACT DETAILS

Do you consent to the practice sending TEXT messages for the purpose of recalls, surveys & updating your details?
Do you consent to the practice sending EMAILS for the purpose of recalls, surveys & updating your details?

Emergency Contact Details

TRANSFER OF RECORDS

I agree to [Practice Name] obtaining my records from my previous doctor, which will mean I will be removed from their practice register.

Transfer Record

ETHNICITY DETAILS

Which ethnic group(s) do you belong to?
Tick the space or spaces which apply to you

Tribe
Smoking Status (If over 15) *
If you are a current smoker or have recently quit, we would like to help you stop to improve your health. Would you like help to stop/stay an ex-smoker?

My declaration of entitlement and eligibility

I am entitled to enrol because I am residing permanently in New Zealand. The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months *

I am eligible to enrol because:

I confirm that I can provide proof of my eligibility

Proof Of Identity

Valid Form of Identification
File Upload *
Maximum upload size: 134.22MB
Passport copy, Photo ID.

My agreement to the enrolment process

NB. Parent or Caregiver to sign if you are under 16 years

I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.

I understand that by enrolling with the [Practice Name] I will be included in the enrolled population of National Hauora Coalition PHO, and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.I understand that if I visit another health care provider where I am not enrolled I may be charged a higher fee.

I have been given information about the benefits and implications of enrolment and the services this practice and PHO provides along with the PHO’s name and contact details.

I have read and I agree with the Use of Health Information Statement. The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Information may be compared with other government agencies, but only when permitted under the Privacy Act.I understand that the Practice participates in a national survey about people’s health care experience and how their overall care is managed. Taking part is voluntary and all responses will be anonymous. I can decline the survey or opt out of the survey by informing the Practice. The survey provides important information that is used to improve health services.I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.

Signatory Details

Authority Details

(where signatory is not the enrolling person)