MyPractice Enrolment Form

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)*

YesNo

Please tick which eligibility criteria applies to you:*

(a) I am a New Zealand Citizen(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 the 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(k) None

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.

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

Take Photo of your evidence - if you need another photo

Do you have a Community Services Card (CSC)?

YesNo

If yes, provide CSC number:

If yes, provide CSC Expiry date

Date

My agreement to the enrolment process

NB. Parent or caregiver to sign if you are under 16 years old

I understand that by enrolling with this practice I will be enrolled with the PHO -Primary Health Organisation (PROCARE). 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.

Enrolment Type*

I choose to enrol with this practice as my regular general practiceCasual or Visitor Only

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 recordsNo transferNot applicable

Name of previous Doctor

Name of previous Medical Practice

Previous Medical Practice Address (if known)

Signature*

Date

Signed by*

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

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

First NameLast Name

Relationship:

Enrolment Form

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