Caring Clinic Doctors: Enrolment Form

Caring
Clinic Doctors ENROLMENT FORM

Level 8, 175 Queen Steet, AUCKLAND CBD 1010
Phone: 09 2222 577 Fax: 09 2222 575 EDI: caring8q (Primary Heath Organisation)
GP2GP: Dr R Sim MCNZ:38537 *NHI (Leave if unsure)

Title
*First *Family Name
Name(s)
Other Names Known By __________/_________/________
(eg. maiden name, etc) Tick *Date of Birth Day Month Year
one you prefer to be known as
*Gender
¨ Male ¨ Female *Place & Country
of Birth
¨ Gender Diverse (please state)
*Physical Occupation
Address Street number Name of Street
Suburb
*High User Health YES / NO
City/Town Postcode Card Card Number
& Expiry Date:
Postal Community YES / NO
Address Services Card
¨ tick if same as above Card Number &
Expiry Date:
Contact Day Phone Night Phone Mobile No (tick box to accept txts) ¨
Email (tick box to accept emails) ¨
Details
Emergency Name of person to contact Relationship Phone Number
contact
*Which ethnic group do you belong to? *Eligibility (see over page)
Tick the space or spaces which apply to you Smoking Status I confirm that, if requested, I can provide proof of my eligibility.
I agree to inform the practice of any changes in my eligibility.
¨ New Zealand European

¨ Current *Eligible under criteria *
(enter applicable letter from list over page)
¨ Māori Iwi: ¨ Ex-Smoker I have read and agree to the Enrolment Process, the
*
Health Information Privacy Poster/Statement, and
¨ Samoan Patient Experience Survey. (Tick)
¨ Cook Islands Maori ¨ Never Smoked NOT Eligible (Tick if not eligible under any
¨ Tongan criteria over page)
¨ Niuean Transfer of Records ¨Yes ¨No ¨Not Applicable
¨ Chinese In order to get the best care possible, I agree to the transfer of my records from
¨ Indian my previous Doctor. I understand I will be removed from their practice register.
Doctor’s Name:
¨ Other such as DUTCH, JAPANESE,
TOKELAUAN, FIJIAN
Address / Location:
Please state: Phone/Fax:
*SIGNATURE *DATE
/ /
Day Month Year
OR Signed by AUTHORITY An authority is the legal right to sign for another person if for some reason they are unable to consent on their own behalf.
11
Full Name of Authority Contact Phone Number Relationship
Address Signature of Authority / /

Day Month Year
Detail the basis of authority (e.g. parent of a child under 16):
Last Updated: 13 Jan 2017

Please read this sheet and identify on your enrolment form which
criteria provides your eligibility to funded health services

Enrolment in the Practice / Primary Health Organisation (PHO)
I am eligible to enrol because I live in New Zealand9 and meet one of the following criteria:
a) I am a New Zealand citizen OR
b) I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010) OR
c) 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 OR
d) 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) OR
e) I am an interim visa holder10 who was eligible immediately before my interim visa started OR
f) 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 OR
g) 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
h) I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their
partner or child under 18 years old) OR
i) I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme OR
j) I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under
the Commonwealth Scholarship and Fellowship Fund.
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 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 the practice sharing my health information with other health providers involved in my healthcare.
HEALTH INFORMATION PRIVACY
I agree to the practice sharing my health information with other health providers involved in my healthcare. 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 also agree to my information being used for practice quality/audit activities and to being included in the practice
screening, recall and health programmes.
I have been informed of the Health Information Privacy statement posters.

9
The definition residing is NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months
10
If a person has an interim visa this means they are waiting for Immigration to finish processing an application as Immigration issues interim visas if the old visa
has run out but the new visa is still being processed. To determine the eligibility of an interim visa holder you should look at what their eligibility status was
immediately prior to being issued the interim visa. For example, the person had a two year work permit and has been issued with an interim visa while
waiting for their application for another two year work permit to be processed. Immigration usually issues Interim visas in a letter form.
11
An authority is the legal right to sign for another person if for some reason they are unable to consent on their own behalf.

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Caring

Clinic Doctors ENROLMENT FORM

GP2GP: Dr R Sim MCNZ:38537 *NHI (Leave if unsure)

¨ New Zealand European

Full Name of Authority Contact Phone Number Relationship

Address Signature of Authority / /

Detail the basis of authority (e.g. parent of a child under 16):

Last Updated: 13 Jan 2017

MY AGREEMENT TO THE ENROLMENT PROCESS

I have been informed of the Health Information Privacy statement posters.

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