• Enrolment Form

  • Otara Family and Christian Health Centre

    Address: 5/120 East Tamaki Road, Otara

    Phone: 09 274 6654

    Fax: 09 274 6694

    Email: reception@otarafamily.health.nz

    EDI: bairdshc

     

  • Preferred Doctor/Registration Number*
  • Date of Birth*
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  • Gender*

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  • Ethnicity Details - Which ethnic group(s) do you belong to?*

  • 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)*
  • Please tick which eligibility criteria applies to you:
  • Browse Files
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  • Take Photo of your eligibility evidence Passport, Visa, Birth Certificate ONLY
  • Community Services Card
  • CSC Expiry date
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    2 digit day, 2 digit month, 4 digit year

  • My agreement to the enrolment process

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

    I intend to use this practice as my regular and on-going provider of general practice/GP/healthcare services.

    I understand that by enrolling with this practice I will be included in the enrolled population of the Primary Health Organisation this practice belongs to 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 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 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. 

  • 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.*
  • Date *
     - -
    2 digit day, 2 digit month, 4 digit year
  • Signed by*

  • Use and confidentiality of your health information

    Otara Family and Christian Health Centre

     

    We will respect your privacy. This fact sheet explains why we collect your information and how we use it.

    Why we collect your information


    We collect health information from you, and sometimes from other health services, to keep a record of your care. When you agree to use our services, we collect health information so we can provide you quality treatment and safe care, as well as meet our legal obligations.

    We also collect your health information to help:

    ·         Keep you and others safe

    ·         Plan and fund health services

    ·         Carry out research approved by an ethics committee

    ·         Train healthcare staff

    ·         Prepare reports and statistics

    ·         Support planning and improvement of health services

    ·         Population health and quality improvement

    ·         Sending reminders or recalls as appropriate.

     

    Confidentiality and information sharing


    We know your health information is private and keeping it safe is important to us.

    ·         Your health practitioner will record relevant information from your consultation in your notes

    ·         We keep your information secure so people cannot see it without permission

    ·         We may securely share your health information with health providers involved in your care, and with other agencies if you agree or if the law allows it

    ·         You do not have to share your health information, but if you choose not to, it may affect your care. Talk to your health practitioner if you have any concerns

    ·         You have the right to know where your information is kept, who can access it, and if the system keeps an access record, who has looked at or updated it

     

    Health information we receive from other health services


    ·         Lab, x-ray, or other test results

    ·         Information from approved national or regional shared health systems, [e.g. Your Health Summary or TestSafe] to help with your care. This may include your medical history, test results, and current medicines

    ·         Letters and updates from hospitals, emergency departments, after-hours services, specialists, and other health providers. This may include discharge summaries and specialist letters

    ·         We may contact a hospital or specialist to follow up a referral or ask for an update about your care

    ·         Letters from screening programmes, such as bowel, breast, or cervical screening. These may include results or notes about whether you attended

    Information we receive from non-health agencies and organisations
    ·         Information or letters from Police, lawyers, Oranga Tamariki, insurance companies, Work and Income, or ACC

    ·         Letters from employers, for example about whether you are fit to work

    ·         Information from the New Zealand Police regarding firearms licences

     

    Information quality


    We must keep your information accurate, up to date, and relevant to your care.

    Your right to access and correct your information


    You have the right to see your health information and ask us to correct it if needed.

    ·         You can ask to see or get a copy of your health information. You do not have to explain why. You may need to show ID. If you ask for a second copy within 12 months, you may need to pay a small administration fee

    ·         You can ask for your health information to be corrected. Practice staff should give you reasonable help. If your healthcare provider does not change it, you can ask for your view to be added to your file

    Many practices offer a patient portal. This lets you see some of your health records online. Ask your practice if they offer one and how to sign up.

     

    How your health information is used


    Here are some ways your health information may be used:

    If your practice works with a Primary Health Organisation (PHO), the PHO may use your information for clinical and administration reasons, including getting public funding for your care.

    ·         The health information we collect is stored electronically by cloud service providers in New Zealand and Australia. These providers may process the information in other countries, but they do not store it there. The information is always encrypted, and the providers meet international security standards

    ·         Health New Zealand (Te Whatu Ora) uses your information to provide care and improve its services

    ·         An authorised health practitioner may carry out a clinical audit to check the quality of the care you received. They may look at health records if needed for the audit

    ·         If you join a health programme, such as immunisation or breast screening, relevant information may be shared with other health agencies

    ·         The Ministry of Health uses your personal details to give you a unique National Health Index (NHI) number. This number helps identify you when you use health services

    ·         The Ministry of Health keeps health information to measure how well services are working and to help plan and fund future services. Auditors may sometimes review records of your visits and may contact you to confirm you received those services

    ·         Births and deaths may be reported electronically to the Births, Deaths and Marriages register to make government services easier to use

     

    Research


    Your health information may be used in research approved by an ethics committee, or in research where details that could identify you have been removed.

    ·         Research that could identify you can only be published if you gave consent first and the study was approved by an ethics committee

     

    Complaints


    You can complain if you are not happy with how your health information is collected or used. If concerns are raised about the care or services we provide, we may share relevant health information with regulators, insurers, indemnity providers, or legal advisers so we can manage and respond to those concerns.

    Talk to your healthcare provider first. If you are still unhappy, you can call the Office of the Privacy Commissioner on 0800 803 909 or the Health and Disability Advocacy Service on 0800 555 050. They can investigate it further.

     

    Further information


    You can find more information on the Health New Zealand / Te Whatu Ora website at https://info.health.nz/privacy/privacy-statement.

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