MyPractice Enrollment 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:

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 your evidence (i.e. Passport, Visa, Birth Certificate) - suggestion: scan and add, or take a photo and attach. *

Browse Files

Take Photo of your eligibility evidence Passport, Visa, Birth Certificate

Community Services Card

YesNo

CSC number

CSC Expiry date

Date

Enrollment I understand that by enrolling with this practice I will be enrolled with the PHO -Primary Health Organisation (PHO). 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 (below). I agree to inform the practice of any change in my eligibility.

Enrollment Type*

I choose to enroll 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

Signature

Clear

Name of previous Doctor*

Name of previous Medical Practice*

Previous Medical Practice Address (if known)

Signature - Please sign on the line*

Clear

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

Signature - Please sign on the line

Clear

Relationship:

Enrolment Form