Northwest Medical Centre 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
You are not eligible for enrollment based on the information provided.

Please contact the clinic at 094122924 for further assistance.
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 minimum of 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 select your proof of eligibility*
Please upload the selected form of evidence; OR Take Photo of your evidence (i.e. Passport, Visa, Birth Certificate, etc)*

Attach Files

Cancelof
OR Take Photo of your evidence (i.e. Passport, Visa, Birth Certificate, etc)
Take Photo of your evidence - if you need another photo
Do you smoke

YesNo (ex-smoker)Never
Community Services Card

YesNo
CSC number
CSC Expiry date

DayMonthYear
Date
Enrollment

I understand that by enrolling with this practice I will be enrolled with the PHO -Primary Health Organisation (Procare). 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 in the accompanying PHO information booklet.

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 practice
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

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Date

DayMonthYear
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:
Should be Empty: