ENROLMENT FORM

Western Bay of Plenty Primary Health Organisation

Contact Details: admin@epichealth.nz

32 Willow Street, Tauranga 3110. Tel: 0800 374 254Fax: 09 355 0508

* Indicates Fields that are COMPULSORY

Fields above for Office Use ONLY

Postal Address (if different from above)

YesNoDay / / Month / Year o of Expiry

Smoking Status (applies to 15 years & over ONLY)

Japanese, Tokelauan Please state:

Smoking is bad for your health. Would you like support to quit? Yes Breast Screening (Females), If eligible, do you consent to being enrolled into the recall system?YesNo Tick the box if you DO NOT want to receive communications by: Text MessagePatient Portal (encrypted) Email (non-secure) How did you find out about us:

In order to get the best care possible, / agree to the Practice obtaining my records from my previous Doctor. / understand / will be removed from their practice register, as / am only able to be enrolled at 1 practice at a time in NZ.

Yes - please request transfer of my records

Western Bay of Plenty PHO Primary Health Services Provider Enrolment FormNES Compliant April 2019

Western Bay of Plenty Primary Health Organisation

*My declaration of entitlement and eligibility*

I am entitled to enrol because I am residing permanently in New Zealand. The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months

I am eligible to enrol because:

aI am a New Zealand citizen (If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)

If you are not a New Zealand citizen please tick which eligibility criteria applies to you (b-j) below: b| hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010) CI 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 dI 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) eI am an interim visa holder who was eligible immediately before my interim visa started fI 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 g criterion in clauses a-f above OR in the control of the Chief Executive of the Ministry of Social Development hI am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old) iI am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university j under the Commonwealth Scholarship and Fellowship Fund

I confirm that I have provided proof of my eligibility

My agreement to the enrolment process NB. Parent or Caregiver to sign if you are under 16 years | intend to use this practice as my regular and on-going provider of general practice (GP) / health care services. | understand that by enrolling with Epic Health Medical Practice, | will be included in the enrolled population of Western Bay of Plenty PHO and my name, address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers. | understand that if I visit another health care provider where I am not enrolled, I may be charged a higher fee. | have been given information or informed 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 shared with other government agencies, but only when permitted under the Privacy Act. | consent to be enrolled in Health Programmes (e.g., Breast Screening (Females), Immunisation, Diabetes); Health data relevant to a programme in which I am enrolled may be sent to the PHO or the external health agency managing this programme. Iunderstand 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. I agree to the Terms and Conditions of Trade of Epic Health Medical Practice and undertake to pay any fees applicable for Practice Services & all costs incurred in collection of any debt for myself & my dependents.

An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf.

Authority Details (where signatory is not the enrolling person)

Western Bay of Plenty PHO Primary Health Services Provider Enrolment Form NES Compliant April2019