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 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. The informationI have provided on the Enrolment form will be used to determine eligibility to recieve 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 patr 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 entitlment 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)
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 email@example.com
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: ____________________________________