Bayside Medical Practice, 6/17 Patteson Avenue, Mission Bay, Auckland 1071
EDI #:bay537sd (P) 09 5286152 (F) 09 5218417 (E) email@example.com
My declaration of entitlement and eligibility
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 providder of general practice / GP / health care services
I understand that by enrolling with this practice, I will be included in the enrolled population with the Primary Health Organisation (PHO) this practice belongs to, 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 vist 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 thee PHO's name and contact details.
I have read and I agree with the Use of Information Statement. The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Informationmay 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 isvoluntary and all responses will be anonymous. I can decline the survey or opt out of the survey by informing the Practice. The survey provides importantinformation 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.
An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf.
Authority Details: (where signatory is not the enrolling person)