Mokopuna Oranga Pūmau - Whānau information form

Mokopuna Oranga Pūmau - Whānau information form

Complete this form to provide information about your mokopuna who has been referred for specialist treatment that may be covered under the Mokopuna Oranga Pūmau healthcare programme.

Mokopuna details
Application date

DayMonthYear
Date of application.
Please ensure the mokopuna name exactly matches with the name registered at your Kōhanga Reo. If you’re unsure, please contact your Kōhanga Reo to confirm.
Mokopuna surname*
Mokopuna first and middle names*
Gender*
Date of birth*

DayMonthYear
Address

Street address

Street Address Line 2

SuburbCity/Town

Post code

Parent / guardian or caregiver details
Parent, guardian or caregiver name*
Relationship to mokopuna*
Contact number*
Email address
Is the mokopuna covered by private medical insurance, eg Southern Cross?*

YesNo

Mokopuna condition
Your General Practitioner will have provided you with a letter referring your mokopuna to a specialist.

Please note any details you can from the letter and upload a copy.
Select condition
Comment
At minimum, please upload the specialist referral letter from the GP.

If you have any other document detailing the nature of the issue and the proposed treatment, please include this if these details are not already outlined in the referral letter.
Please upload your referral letter and any other relevant documents*

Please upload or drag and drop your files here
Acceptable file types are: pdf, jpg, jpeg, png, gif. Cancelof
Please record the details of the specialist you’re planning to see. Your GP may have identified someone specific, or you may have found someone to see in your area.
Name of nominated specialist*
Enter specialist name.
Nominated specialist email*
xyz@doctors.co.nz
Location of nominated specialist*
Enter specialist location.
Nominated specialist contact number*
Eg. 04 xxx xxxx.

Authorisation
I Name on this Date declare:
That all information provided in this form is true and correct.
That I will provide any additional information requested of me in order to confirm this request.
Review the form to ensure you have completed all relevant fields then click Submit.
Should be Empty: