MyPractice Enrollment Form

  • 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*
     - -
  • Gender*

  •  -
  •  -
  •  -
  • 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
    Cancelof
  • Community Services Card
  • CSC Expiry 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. 

     

  • 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 *
     - -
  • Signed by*
  • Should be Empty: