MyPractice Enrolment Form

Enrollment Type *

I choose to enroll with this practice as my regular general practice Casual or Visitor Only

My declaration of entitlement and eligibility

(for public funding)

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

Yes No

Please tick which eligibility criteria applies to you:

Please upload your evidence (i.e. Passport, Visa, Birth Certificate, proof of employment or study course, etc) - 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

Community Services Card

Yes No

CSC number

CSC Expiry date

Date

WINZ Client number

Enrollment

I understand that by enrolling with Epic Health Medical Practice I will be enrolled with the Western Bay of Plenty PHO -Primary Health Organisation. My name, address and other identification details will be included on both the practice and PHO enrolment registers.

I understand that if I visit another 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 with the PHO and their contact details.

I have read and I agree with the Health Information Privacy Statement in the accompanying PHO information booklet.

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

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, please request transfer of my records No (do not transfer)

Name of previous Doctor

Name of previous Medical Practice

Previous Medical Practice Address (if known)

Signature

Clear

Date

Signed by

Patient Authorised Person (Parent or Caregiver to sign if under 16 years)

Name of authorised Person with legal right to sign for this patient:

First Name Last Name

Relationship: