Enrolment Form Pegasus 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 below No - 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 Development 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) i. I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme 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 confirm that, if requested, I can provide proof of my eligibility *

Yes

Please upload your evidence (i.e. for New Zealand citizens either Passport or Birth Certificate. 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 you need another photo

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 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 *

Clear

Date of signature *

Date

Who signed this? *

Self-signing Authority

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 Name Last Name

Relationship:

Phone Number

Area Code Phone Number

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

By signing this form, you agree on the terms of trade attached.

Terms of Trade

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

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.

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

2. 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.

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

4. 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 within 7 days .

5. 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.

6. Failure to contact us to cancel your appointment in time may result in a Did Not Attend (DNA) charge of $15 being added to your account. Please ensure you cancel all booked appointments as we have a high demand for appointments each day.

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

8. Patient behavior is expected to be respectful and understanding. We are a busy practice and healthcare of the community is our priority, this means there may be delays in seeing your clinician from time to time.

Online Enrolment Form