Enrolment Form Silverstream Medical Centre

My declaration of entitlement and eligibility

I am entitled to enrol because I am residing permanently in New Zealand. (plan to be in New Zealand for at least 183 days in the next 12 months)*

Yes - fill in eligibility belowNo - do not fill in eligibility below

I am eligible to enrol because:

a. I am a New Zealand citizen.

If you are NOT a New Zealand citizen - please tick which eligibility criteria applies to you (b-j) below:

b. I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010).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.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).e. I am an interim visa holder who was eligible immediately before my interim visa started.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.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 in thee control of the Chief Executive of the Ministry of Social Developmenth. 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)i. I am participating in the Ministry of Education Foreign Language Teaching Assistantship schemej. 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 confirm that, if requested, I can provide proof of my eligibility*

Yes

Please upload your evidence (i.e. for New Zealand citizens over 18 years old, either New Zealand Passport or Birth Certificate and 2 forms of supporting identity information, one with a photo ( driver's license, community services card). For Non New Zealand citizens Passport and Visa) - suggestion: scan and add, or take a photo and attach. *

Browse Files

Take Photo of your evidence (i.e. Passport, Visa, Birth Certificate, etc)

Take Photo of your evidence - ( If on temporary Visa, include copy of Customs stamp with date of entry to New Zealand)

Do you agree to the enrolment process as outlined?*

NoYes My agreement to the enrolment process 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 this practice, I will be included in the enrolled population of Pegasus Health Charitable Ltd PHO (Primary Health Organization) 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 agree with the Use of Health Information Statement. (Links to the information under "enrolment" on the website) . * 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*

Date of signature*

Date

Who signed this?*

Self-signingAuthority

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)

Name of authority:

First NameLast Name

Relationship:

Phone Number

Area CodePhone Number

Basis of authority (i.e. parent of a child under 16 years of age, parent or spouse with dementia, etc)

I understand that this request to enroll will be reviewed depending on capacity and I will be notified when it has been accepted.*

Yes

Additional Information Initial New Patient Medical Questionnaire 1. Do you have or have had any of the following medical conditions:*

2. Please your regular medications*

3. Please list any surgeries

4. Please list any allergies

5. Do you drink alcohol? if so what is the average per week

6. Are you a smoker, present or past? If yes, how many packets /day

By signing this form, you ackowledge that you have read and agree to the terms of trade hereafter. Please download New Patient Questionaire, Complete and email to reception@silverstreammedicalcentre.co.nz

Terms of Trade

The following Terms of Trade apply to services provided by Silverstream Medical Centre to its patients.

By Signing, you hereby agree to the Terms and Conditions of Trade as stated

1. Our fees are available upon request. These charges take into account the following factors:

a. The time spent

b. The complexity of treatment

c. The costs of running a medical practice

d. The funding available from the government, public agencies and other sources.

2. Unless by prior arrangement, all services shall be paid on the date of the service.

3. We would be very concerned if any patient deferred seeking medical help due to the cost. If this is the case, please, talk to your doctor or the practice manager so other payment options can be arranged.

4. Payment shall be accepted by cash, Cheque, Eftpos, Credit Card or automatic payment.

5. Where it is agreed that payment need not be paid on the day of the service, it shall be paid within 7 days of the date of the invoice or by the date agreed with the Doctor or Practice Manager. An account fee of $10 is added to all accounts not paid on the day.

6. Where patients are in breach of agreed payment terms, referral of the debt, including the provision of necessary contact details may be sent to a debt collecting agency. Costs incurred to recover outstanding monies will be charged to the patient. This may result in patient name and address entered into the computer Bureau default listing which will have an impact on patient's credit rating.

7. Variations to the Terms of Trade may occur from time to time and Silverstream Medical Centre will notify the patient by way of invoice - receipt of which shall be deemed acceptance by the patient.

Patient/Representative name: ____________________________________

Request to Enrol Form