ENROLMENT FORMv5

Title

Given Name*

e.g. First Name

Other Given Name(s)

e.g. Middle Name(s)

Family Name*

e.g. Surname

Date of Birth*

Place of Birth*

Country of Birth*

What is your Occupation

Gender*

MaleFemaleOther

House (or RAPID) Number and Street Name*

e,g. 221b Baker St

Suburb*

Town/City and Postcode*

House Number and Street Name or PO Box Number

Suburb

Town / City and Postcode

Mobile Phone*

Home Phone*

Email

example@example.com

Name*

Relationship*

Mobile (or other) Phone*

Tick the space of spaces which apply to you*

Your Iwi

Your Hapū

I am entitled to enrol

because I am residing permanently in New Zealand* The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months

I am eligible to enrol because

I am a New Zealand citizen (If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)*

If you are not a New Zealand citizen, please tick which eligibility criteria applies to you

I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)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 yearsI have a current work visa/permit and can show that I am legally able to be in New Zealand for at least 2 years (previous visas/permits included)I am an interim visa holder who was eligible immediately before my interim visa startedI 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 traffickingI 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 DevelopmentI 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 am participating in the Ministry of Education Foreign Language Teaching Assistantship schemeI 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

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 Nga Kakano Foundation I will be included in the enrolled population of Ngã Mataapuna Oranga Primary Health Organisation 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 healthcare 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 agree with 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 this Practice shares limited information with the BOP District Health Board BOPDHB

I understand that this Practice shares my information with other health professionals that are involved in my care. Other health professionals may add to my health records during services provided to me and use that information to provide appropriate care.

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. 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

Enrolment Status*

I am Existing EnrolmentI am New Enrolment

Community Services Card*

YesNo

Day/Month/Year of Expiry

Date

Card Number

Reference

High User Card*

YesNo

Day/Month/Year of Expiry

Date

Card Number

Are you a smoker?*

YesNoPastRecently Quit

Would you like us to assit you to stop smoking?*

YesNo

I agree to be on the recall list for medcal screening*

YesNo

I agree to receive a reminder text for medical recalls*

YesNo

Women Aged 45-69 years: I agree to being enrolled with Breast Screen Aotearoa

YesNo

Women Aged 45-69 years: I agree to being enrolled with the National Cervical Screening Programme.

YesNo

Do you suffer from any known illnesses such as Diabetes, Asthma, Heart condition?

Please Stipulate.

Note: GP Services enrolment payment terms and conditions:*

I agree the practice (GP Services) is entitled to charge a fee for services and I understand that I am financially responsible for payment of those services.I understand that payment is to be made on the dayAccounts outstanding after 90 days may be directed to a Debt Collection Agency.I agree to pay Agency charges associated with recovery

In order to get 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.

Transfer of Records*

YES please request transfer of my recordsNo TransferNot Applicable

Previous Doctor and / or Practice Name

e.g. Nga Kakano

Practice Address/Location

e.g. 50 Jellicoe St \Te Puke

Next of Kin Name*

Next of KIn Address *

Next of Kin Contact Num*

Do You Have Medical Insurance ?*

YesNo

Medical Insurance Details.

	Name
Insurer
Number
Reference

Do You Have Children?*

YesNo

Children (Please add details)

	Name	Sex	Ethnicity	Date of Birth
Child One
Child Two
Child Three
Child Four
Child Five

Code of Health and Disability Services Consumers' Rights

Note: you can read your rights by clicking here or view video here

The Complaints Process

Click to view Complaints Process

Confirm*

I have read the Code of Health and Disability Services Consumers Rights and I understand I have these rights when receiving Nga Kakano health services. I AGREEI am aware of the complaint process. I AGREE

Attachments

Please Attach your Birth Certificate or Passport ID

Signatory Details*

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 (Where signatory is not the enrolling person)
Authority Full Name
Relationship
Contact Number
Basis of Authority (e.g parent of a child under 16 years of age)

Signature*

Clear

Date*

Date

NMO PHO Provider Enrolment Form

Q:05 ualityReviewed Documents

Are you Applicable

On Submission

Ensure Redirects are enabled on your browser

"Allowing Pop-ups and Re-directs

Enrolment Form

Usual Residential Address

Postal Address

Contact Details

Emergency Contact

Ethnicity Details

My declaration of entitlement and eligibility

My agreement to the enrolment process*

New Enrolments Section to Complete*

In order to get 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.

Code of Health and Disability Services Consumers' Rights