MyPractice Enrolment Form

My declaration of entitlement and eligibility.

I reside within Hokianga and can provide verification of my address*

YesNo

Please tick which eligibility criteria applies to you:

I am a New Zealand CitizenI 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 years.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).I am an interim visa holder who was eligible immediately before my interim visa started.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.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 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 FundNone

Please upload evidence of identification (i.e. Passport, Visa, Birth Certificate, etc). Suggestion: scan and add, or take a photo and attach.*

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Please upload verification of address (Utilities bill – power, phone account). 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, Utilities bill – power, phone account, etc)

Take Photo of your evidence - if you need another photo

Smoking Status

Never SmokedSmokerEx-Smoker

Number of years since quitting

Would you like help to stop smoking?

YesNo

Community Services Card

YesNo

CSC number

CSC Expiry date

Date

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)Mahitahi Hauora, 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’sname and contact details.
I have read and I understandthe 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’shealth care experience and how theiroverall care
is managed. Taking part is voluntary and allresponses will be anonymous. I can decline the survey or opt out of the survey by
informing the Practice. The survey provides important information thatis 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.

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:

Health Information Privacy statement Your personal health information and how it is used. CONSENT TO COLLECT PATIENT HEALTH INFORMATION Patients directly consent to health information (patient data) being collected when they sign an enrolment form with their family doctor or visit a GP practice.Your health information will be shared with others involved in your healthcare.This helps to improve care for individuals, and with the health information from many people collected together it can be used to improve health services, care for other patients and future generations as well as community wellbeing. Patient data is used for the following reasons: • To measure and improve the quality of healthcare• To understand the frequency and severity of common major health problems• To ensure that the differences in health status between different population groups are reduced• To identify health prevention and promotion strategies• To advocate for changes and improvement to health care funding and delivery• To support some health research, subject to approval by an ethics committee• To meet contract requirements with the Ministry of Health needed to obtain funding to reduce the cost of your GP visits WHAT INFORMATION IS COLLECTED? • Information about you (name, date of birth, gender, address, ethnicity, citizenship, NHI number)• Information about your health and your medical conditions and measurements• Information about health services that are being provided to you e.g. medications, immunisations, health screening, lab results• Information about the financial transactions around consultation chargesInformation is not collected from your consultation notes (the progress notes your GP made on your file regarding your visits). SECURITY & PRIVACY OF PATIENT DATA A PHO is a Primary Health Organisation. Patient data is sent securely to the PHO which stores this information in a data warehouse. The data provides a single source of information for practice clinicians. It is able to produce reports that help manage and improve services for patients.Some health information we collect and generate is stored electronically by cloud service providers located in Australia. This information may also be processed (but not stored) on cloud servers located in other overseas countries. This information is encrypted at all times and these providers comply with internationally recognised security standards.Information is also sent to the Ministry of Health to allocate funding subsidies which reduce the cost of GP visits.Robust protocols and processes have been developed for collecting and storing this data to make sure it is kept safe and protected.Our processes are fully compliant with the Privacy Act 1993 and HealthInformation Privacy Code. CONSENT OPTIONS If you do not consent to health information such as medical conditions, medications and lab results being collected, then you may ‘opt-off’ by letting your practice know.