ENROLMENT FORM

58 Rawhiti Road, Manly, Auckland - Phone: 09 424 9050 

Email:  reception@manlymedical.co.nz  EDI:  Manlywha

Please be aware the enrolment process may take up to 2 weeks.

For government funding purposes please provide the following proof of identification and eligibility - NZ birth certificate and photo ID e.g drivers licence or passport. 

If not a NZ citizen a copy of your passport and visa is mandatory. 

 

TRANSFER OF RECORDS In order to get the best care possible, I agree to the Practice obtaining my records from my previous doctor within New Zealand. I also understand that I will be removed from their practice register, as I am only able to be enrolled at 1 practice at a time in New Zealand. If your records are overseas, it is your responsibility to obtain them

- 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 / health care 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.

Terms and Conditions of Trade

The following Terms of Trade apply to services provided by Manly Medical Centre to its patients.

· Any changes to the Terms and Conditions of Trade need to be agreed to in writing by both parties.

· No staff member of Manly Medical Centre may agree to any terms other than as written in this contract.

· Manly Medical Centre agrees not to use or disclose any information more than is reasonably necessary in the circumstances for its genuine business purposes

· No goods supplied by Manly Medical Centre may be returned for credit.

· Supply of goods for personal use will be covered by the Consumer Guarantees Act 1993.

· Variations to the Terms of Trade may occur from time to time, and Manly Medical Centre will notify the patient by way of invoice - receipt of which shall be deemed to be acceptance by the patient.

I acknowledge that I have read and understand the above debt policy and agree to abide by these terms of payment.

I hereby agree to the Terms and Conditions of Trade as stated.

Manage My Health (MMH) Patient Portal (Optional)

I acknowledge that Manly Medical Centre can give me secure access to my personal health information via the patient portal.

- I will keep my username and password secure.

- If I share family email address and password with my partner, I acknowledge that they can share my information.

- I understand that in future there may be a charge for some patient portal services.

- The email address provided is my own personal email address.