Patient Enrolment Form

Name*
Prefix First Middle Last
Preferred Name
Other Names Known By (e.g. maiden name)
Gender*
Place / Country of birth*
Date of Birth*

Day
Month
Year
Physical Address*
Rapid Number as well as R.D. number please

Street Address City/Town Suburb Postcode
Postal Address (If different from physical address)*
- Yes
- No
Postal Address*
Rapid Number as well as R.D. number please

Street Address City/Town Suburb Postcode
Community Services Card*
- Yes
- No
Community Services Card Number*
Community Services Card Expiry Date*

Day
Month
Year
High User Health Card*
- Yes
- No
High User Health Card Number*
High User Health Card Expiry Date*

Day
Month
Year
Contact Details
Day Phone
Night Phone
Mobile Phone*
Email*
Electronic Contact
I wish to be contacted by Text and /or Email for services that are due to me by Waihopai Health Services.
Tick one or both options-
- Text
- Email
Next of Kin
Name
First Last
Relationship
Phone
Mobile Phone*
Address
Street Address City/Town Suburb Postcode Country
Emergency contact
Name of person to contact
First Last
Relationship
Mobile Phone*
Phone
Address
Street Address City/Town Suburb Postcode Country
Which ethnic group do you belong to?*
- Māori
- New Zealand European
- Samoan
- Cook Islands Maori
- Tongan
- Niuean
- Chinese
- Indian
- Other such as DUTCH, JAPANESE, TOKELAUAN. Please state:
Other such as DUTCH, JAPANESE, TOKELAUAN. Please state:*
Do you need an interpreter?
- Yes
- No
Please Select Your Smoking Status
- Never Smoked
- Smoker
- Ex Smoker
Approx. Year:*
Enter any past medical history and other impairments or disabilities.*
Allergies- Please list any allergic reactions to medication or food*
What was your reaction?
Occupation(s)*
Transfer of Records*
In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.
- Yes
- No
- Not applicable
Doctor’s Name:
Address/Location:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Usual Pharmacy:
Enrolment in the Practice/Primary Health Organisation (PHO)
Family Health
Has your Mother, Father, Brother, or Sister suffered from Diabetes, Cancer, High Blood Pressure, Heart Disease, Stroke, Kidney Disease or other serious health problem?
Family Member E.g. Mother Condition/Illness e.g.Heart attack Age at Onset e.g.56 Age at Death e.g.72
Dependants (under 16years of age) listed on this form will also be enrolled in the PHO as long as I am legally entitled to sign on their behalf (see below)
NHI First Names Family Name Gender Ethnicity/Ethnicities (Mother and Father) Date of Birth
I intend to use Waihopai Health Services as my regular and ongoing provider of general practice / GP / First Level primary health care services. I am eligible to enrol because I live in New Zealand and meet one of the following criteria: (Proof of Eligibility needs to be provided.)
- a) I am a New Zealand citizen OR
- b) I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010) OR
- c) I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years OR
- d) I have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included) OR
- e) I am an interim visa holder who was eligible immediately before my interim visa started OR
- f) I am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people trafficking OR
- g) I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a–f above OR
- h) I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old) OR
- i) I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme OR
- j) I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund.
I choose to enrol with this practice as my regular and on going provider of general practice / GP / First Level primary health care services

I understand that by enrolling with this practice I will be enrolled with the Primary Health Organisation (PHO) this practice belongs to, and my name address and other identification details will be included on both the Practice and the PHO Enrolment Register.

I understand that if I visit another provider where I am not enrolled I may be charged a higher fee.

I understand that an administration fee will be charged to me if my account is unpaid by the last working day of each month.

I understand that if my account is outstanding after a further 30 days that the account may be passed to a collection agency and all fees associated with collection will be payable by me.

I have been given information about the benefits and implications of enrolment with the PHO, and their contact details.

I have read and I agree with the Health Information Privacy Statement .

I agree to inform the practice of any changes in my eligibility.

1The definition of residing in New Zealand is that you intend to be resident in New Zealand for at least 183 days in the next 12 months.
2 An authority is the legal right to sign for another person if for some reason they are unable to consent on their own behalf.
Attach Files for Proof of Eligibility
Drop files here or

Accepted file types: jpg, pdf, doc, docx, Max. file size: 2 MB, Max. files: 6.
you can attach multiple files if needed.
jpg, pdf, doc, docx file types are accepted.
Max file size 2MB per file
I agree to above and have submitted true and correct details in my enrolment.*
- Agree
- Disagree
Date*
DD slash MM slash YYYY
Signed by AUTHORITY
- yes
- no
Full Name of Authority*
First Middle Last
Contact Phone Number*
Relationship*
Address*
Street Address City Suburb Postal Code
Date*
DD slash MM slash YYYY
Detail the basis of authority (e.g. parent of a child under 16):*
Health Information Privacy Statement
I understand the following:

Access to my health information

I have the right to access (and have corrected) my health information under Rules 6 and 7 of the Health Information Privacy Code 1994.

Visiting another GP

If I visit another GP who is not my regular doctor, I will be asked for permission to share information from the visit with my regular doctor or practice.

If I have a High User Health Card or Community Services Card and I visit another GP who is not my regular doctor, he/she can make a claim for a subsidy, and the practice I am enrolled in will be informed of the date of that visit. The name of the practice I visited and the reason(s) for the visit will not be disclosed unless I give my consent.

Patient Enrolment Information

The information I have provided on the Practice Enrolment Form will be:
- held by the practice
- used by the Ministry of Health to give me a National Health Index (NHI) number, or update any changes
- sent to the PHO and Ministry of Health to obtain subsidised funding on my behalf
- 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.
Health Information

Members of my health team may:
- add to my health record during any services provided to me and use that information to provide appropriate care
- share relevant health information to other health professionals who are directly involved in my care e.g. HealthOne
Audit

In the case of financial audits, my health information may be reviewed by an auditor for checking a financial claim made by the practice, but only according to the terms and conditions of section 22G of the Health Act (or any subsequent applicable Act). I may be contacted by the auditor to check that services have been received. If the audit involves checking on health matters, an appropriately qualified health care practitioner will view the health records.

Health Programmes

Health data relevant to a programme in which I am enrolled (e.g. Breast Screening, Immunisation, Diabetes) may be sent to the PHO or the external health agency managing this programme.

Other Uses of Health Information

Health information which will not include my name but may include my National Health Index Identifier (NHI) may be used by health agencies such as the District Health Board, Ministry of Health or PHO for the following purposes, as long as it is not used or published in a way that can identify me:
- health service planning and reporting
- monitoring service quality, and
- payment.
Research

My health information may be used for health research, but only if this has been approved by an Ethics Committee and will not be used or published in a way that can identify me.

Except as listed above, I understand that details about my health status or the services I have received will remain confidential within the medical practice unless I give specific consent for this information to be communicated.
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Comments
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Contact Details

Next of Kin

Emergency contact

Enrolment in the Practice/Primary Health Organisation (PHO)

Health Information Privacy Statement

Get In Touch

Practice Hours

Family Member E.g. Mother	Condition/Illness e.g.Heart attack	Age at Onset e.g.56	Age at Death e.g.72

NHI	First Names	Family Name	Gender	Ethnicity/Ethnicities (Mother and Father)	Date of Birth