MyPractice Enrolment 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, proof of employment or study course, etc) - suggestion: scan and add, or take a photo and attach.

Browse Files

Take Photo of your evidence (i.e. Passport, Visa, Birth Certificate, etc)

Take Photo of your evidence - if you need another photo

Community Services Card

YesNo

CSC number

CSC Expiry date

Date

Enrolment

I understand that by enrolling with this practice I will be enrolled with the PHO - Primary Health Organisation WellSouth. 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.

I agree to all fees and charges associated with my appointment, to be paid on the same day. Cromwell Medical Centre does not run accounts.

I agree to abide by Cromwell Medical Centre policies.

Enrolment Type

I choose to enrol 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

Name of previous Doctor

Name of previous Medical Practice

Previous Medical Practice Address (if known)

NHI Number (if known)

Signature

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

Relationship:

Health Information Privacy statement

Your personal health information and how it is used.

CONSENT TO COLLECT PATIENT HEALTH INFORMATION

Patients directly consent to health information (patient data) being collected when they sign an enrolment form with their family doctor or visit a GP practice.

Your health information will be shared with others involved in your healthcare.

This helps to improve care for individuals, and with the health information from many people collected together it can be used to improve health services, care for other patients and future generations as well as community wellbeing.

Patient data is used for the following reasons:

• To measure and improve the quality of healthcare
• To understand the frequency and severity of common major health problems
• To ensure that the differences in health status between different population groups are reduced
• To identify health prevention and promotion strategies
• To advocate for changes and improvement to health care funding and delivery
• To support some health research, subject to approval by an ethics committee
• To meet contract requirements with the Ministry of Health needed to obtain funding to reduce the cost of your GP visits

WHAT INFORMATION IS COLLECTED?

• Information about you (name, date of birth, gender, address, ethnicity, citizenship, NHI number)
• Information about your health and your medical conditions and measurements
• Information about health services that are being provided to you e.g. medications, immunisations, health screening, lab results
• Information about the financial transactions around consultation charges
Information is not collected from your consultation notes (the progress notes your GP made on your file regarding your visits).

SECURITY & PRIVACY OF PATIENT DATA

A PHO is a Primary Health Organisation. Patient data is sent securely to the PHO which stores this information in a data warehouse. The data provides a single source of information for practice clinicians. It is able to produce reports that help manage and improve services for patients.

Some health information we collect and generate is stored electronically by cloud service providers located in Australia. This information may also be processed (but not stored) on cloud servers located in other overseas countries. This information is encrypted at all times and these providers comply with internationally recognised security standards.

Information is also sent to the Ministry of Health to allocate funding subsidies which reduce the cost of GP visits.

Robust protocols and processes have been developed for collecting and storing this data to make sure it is kept safe and protected.

Our processes are fully compliant with the Privacy Act 1993 and Health Information Privacy Code.

CONSENT OPTIONS

If you do not consent to health information such as medical conditions, medications and lab results being collected, then you may ‘opt-off’ by letting your practice know.