Enrolment Form

Filling and submitting this form is a request to enrol and does not automatically lead to enrolment.

Patient Information

First Name *

Middle Name

Last Name *

Gender *

Please fill your name as in passport

Date of Birth *

Country of Birth

Place of Birth

Ethnicity *

Contact Information

Address *

Email *

Phone *

Emergency Contact Name *

Emergency Contact Phone *

Eligibility

Please select all that apply:

I am a New Zealand citizen (inc. Cook Islands, Niue or Tokelau).I am entitled to enrol because I am residing in New Zealand and meet eligibility criteria (intended stay 183+ days in next 12 months).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 years.I have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years.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.I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses above.I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding.

Upload Proof of Identity *

Please upload a photo or scan of your passport, visa, or driver licence.

Tap to upload or take a photoImage or PDF, max 5 MB

Consents

My consent and agreement to the enrolment process. *

• I intend to use this practice as my regular and ongoing provider of general practice / GP / First Level primary health care services.

• I understand that by enrolling with this practice I will be enrolled with the Primary Health Organisation (PHO) this practice belongs to, and my name, address and other identification details will be included on both the Practice, PHO and National Enrolment Service 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 and the services this practice and PHO provides, and their contact details.

• 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 eligibility.

I agree to all of the above consents. *

Health Information Privacy Statement

Please read and sign

Use and confidentiality of your health information (fact sheet)

Your privacy and confidentiality will be fully respected. This fact sheet sets out why we collect your information and how that information will be used.

Purpose

We collect your health information to provide a record of care. This helps you receive quality treatment and care when you need it.

We also collect your health information to help:

keep you and others safe
plan and fund health services
carry out authorised research
train healthcare professionals
prepare and publish statistics
improve government services.

Confidentiality and information sharing

Your privacy and the confidentiality of your information is really important to us.

Your health practitioner will record relevant information from your consultation in your notes.
Your health information will be shared with others involved in your healthcare and with other agencies with your consent, or if authorised by law.
You don't have to share your health information, however, withholding it may affect the quality of care you receive. Talk to your health practitioner if you have any concerns.
You have the right to know where your information is kept, who has access rights, and, if the system has audit log capability, who has viewed or updated your information.
Your information will be kept securely to prevent unauthorised access.

Information quality

We're required to keep your information accurate, up-to-date and relevant for your treatment and care.

Right to access and correct

You have the right to access and correct your health information.

You have the right to see and request a copy of your health information. You don't have to explain why you're requesting that information, but may be required to provide proof of your identity. If you request a second copy of that information within 12 months, you may have to pay an administration fee.
You can ask for health information about you to be corrected. Practice staff should provide you with reasonable assistance. If your healthcare provider chooses not to change that information, you can have this noted on your file.

Many practices now offer a patient portal, which allows you to view some of your practice health records online. Ask your practice if they're offering a portal so you can register.

Use of your health information

Below are some examples of how your health information is used.

If your practice is contracted to a Primary Health Organisation (PHO), the PHO may use your information for clinical and administrative purposes including obtaining subsidised funding for you.
Your District Health Board (DHB) uses your information to provide treatment and care, and to improve the quality of its services.
A clinical audit may be conducted by a qualified health practitioner to review the quality of services provided to you. They may also view health records if the audit involves checking on health matters.
When you choose to register in a health programme (eg immunisation or breast screening), relevant information may be shared with other health agencies.
The Ministry of Health uses your demographic information to assign a unique number to you on the National Health Index (NHI). This NHI number will help identify you when you use health services.
The Ministry of Health holds health information to measure how well health services are delivered and to plan and fund future health services. Auditors may occasionally conduct financial audits of your health practitioner. The auditors may review your records and may contact you to check that you received those services.
Notification of births and deaths to the Births, Deaths and Marriages register may be performed electronically to streamline a person's interactions with government.

Research

Your health information may be used in research approved by an ethics committee or when it has had identifying details removed.

Research which may directly or indirectly identify you can only be published if the researcher has previously obtained your consent and the study has received ethics approval.
Under the law, you are not required to give consent to the use of your health information if it's for unpublished research or statistical purposes, or if it's published in a way that doesn't identify you.

Complaints

It's OK to complain if you're not happy with the way your health information is collected or used.

Talk to your healthcare provider in the first instance. If you are still unhappy with the response you can call the Office of the Privacy Commissioner toll-free on 0800 803 909, as they can investigate this further.

For further information

Visit www.legislation.govt.nz to access the Health Act 1956, Official Information Act 1982 and Privacy Act 1993.

The Health Information Privacy Code 1994 is available at www.privacy.org.nz. You can also use the Privacy Commissioner's Ask Us tool for privacy queries.

A copy of the Health and Disability Committee's Standard Operating procedures can be found at ethics.health.govt.nz/operating-procedures

Further detail in regard to the matters discussed in this Fact Sheet can be found on the Ministry of Health website at health.govt.nz

I agree to all of the above health information privacy statements. *

Transfer of Records *

I request that my medical records be transferred from my previous medical practice / GP to Selwyn House Medical Centre.

Previous Medical Centre / GP Name

I have not enrolled with a family doctor before and no records need to be transferred.

Signature

Who is signing this form? *

Myself (16+ years)Parent / Legal Guardian / Authority

Please sign in the box below:

Signature *