Poutiri Enrolment Form

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

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

Evidence sighted (Office use only)

Yes

I intend to use this practice as my regular and ongoing 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 this practice’s Primary Health Organisation (PHO) [Western Bay PHO], 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 I understand the Use of Health Information Statement. 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.

Signature

Date*

Date

Signed by?*

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):

Full Name of Authority*

First NameLast Name

Relationship*

Contact Phone*

Legal basis of authority (e.g. parent of a child under 16 years of age)*

1. Are you interested in other Poutiri services?*

YesNo

If yes, please tick the services you are interested in

2. Are you on regular medications?*

YesNo

3. If Yes, next script due

Date

My preferred pharmacy / chemist is:

Full Name*

TitleFirst NameOther Given Name(s)Family Name

Other Name(s)

Other NameOther NamePreferred Name

Mobile Phone*

Home Phone

Can you provide proof of Identity?*

YesNo

Unfortunately your online enrolment cannot be processed any further, to progress your enrolment please contact our team at Poutiri Wellness Centre at 35 Commerce Lane, Te Puke or by phoning 0800 573 0091

ID can be uploaded here, OR brought in person to our main office on 35 Commerce Lane, Te Puke.

I choose to:*

Present my ID in personUpload my ID

If presenting ID in person, please note your enrolment will not started until your ID has been sighted by our team.

Please upload your ID evidence (2 FORMS OF ID - your passport or birth certificate, and photo ID. If applicable we also need NZ citizenship, residency or visa). *

Take Photo of your ID evidence - if you need another photo *

Are you aware of your patient rights?*

YesNo

If no, please click to watch video (Code of Health and Disability Consumer Rights videos | Health Navigator NZ) or read your rights (Code of Health and Disability Services Consumers' Rights - Health and Disability Commissioner (hdc.org.nz) and then return to answer this question.

Are you aware of Poutiri’s complaints process?*

YesNo

The Poutiri Wellness Clients Rights and Complaints Process Document is available to download from our website. For more information, you can also visit Making a complaint - Health and Disability Commissioner (hdc.org.nz)

Ngā mihi nui, we look forward to getting to know your health needs. Mahitahi – working together to help you be well, get well and live well.

My declaration of entitlement and eligibility

My declaration of entitlement and eligibility