Browns Bay Medical Centre 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 including the page with your signature. (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 Browns Bay Medical Centre I will be included in the enrolled population of Comprehensive Care PHO and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers. Personal details and clinical notes may be shared with other Health Providers, or third-party requests as part of my healthcare e.g. ACC, Insurance Company requests, Ministry of Health, WINZ etc.

I understand that if I visit another health care provider where I am not enrolled I may be charged a higher fee.

I understand that full payment is due at the time of consultation. I understand there is an extra charge for the first visit. Accounts outstanding at 3 months, unless other arrangements have been made, maybe sent to a collection agent. Collection charges are the responsibility of the patient.

I understand that to cancel a consultation without incurring a fee I need to give 2 hours’ notice.

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 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 Health Information Privacy statement (below).

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 agree to inform the practice of any change in my eligibility.

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)

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:

The Use of Health Information Statement.

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 involved in providing that health programme.
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 uses 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.

BBMC Enrolment Application Form