Enrolment Form | Te Puna Hauora o Te Raki Paewhenua

If you are not a New Zealand citizen, please tick which eligibility criteria applies to you (b - j) below:

I 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 the control of the Chief Executive of the Ministry of Social Development

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)

I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme

I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund

Proof of Eligibility

1. New Zealand Passport
2. Birth Certificate or Citizenship
3. Or any relevant visas and Passport if not a Citizen

Valid files are JPG, PNG, GIF, PDF and WEBP. File size maximum is 2MB.
Hit Control or Command + click with mouse to choose multiple files

My agreement to the enrolment process:

ENROLMENT AGREEMENT:


1.) I intend to use Te Puna Hauora as my regular and on-going provider of general practice / GP / healthcare services.

2.) I understand that by enrolling with Te Puna Hauora, I will be included in the enrolled population of the Primary Health Organisation Te Puna Hauora belongs to and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers

3.) I understand that if I visit another healthcare provider where I am not enrolled, I may be charged a higher fee.

4.) I have been given information about the benefits and implications of enrolment and the services Te Puna Hauora and the PHO provides along with the PHO's name and contact details.

5.) 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.

6.) I understand that Te Puna Hauora participates in a national survey about people's healthcare 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 Te Puna Hauora. The survey provides important information that is used to improve health services.

7.) I agree to inform Te Puna Hauora of any changes in my contact details and entitlement and / or eligibility to be enrolled.


EMAIL ACKNOWLEDGMENT AND AGREEMENT:

Risks of using email
For the ease of our tangata / whānau, our clinic would like to offer the opportunity to communicate by email. Transmitting tangata / whānau information poses several risks and tangata / whānau should not agree to communicate with the staff via email without understanding and accepting these risks.

The risks include, but are not limited to, the following:
• The privacy and security of email communication cannot be guaranteed.
• Email senders can misaddress, resulting in it being sent to many unintended recipients.
• Employers / online services may have a legal right to inspect and keep emails that pass through their system.
• Even after deletion of the email, back‐up copies may exist on a computer.
• Email is easier to falsify than signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email.
• Emails can introduce viruses, generally damage, or disrupt the computer.
• Email can be used as evidence in court.

Conditions of using email
Our clinic will use reasonable means to protect the security and confidentiality of email information sent and received—however, we cannot guarantee the security of email communication. Thus, tangata / _hanau must consent to the use of email for tangata / whanau information, billing, and communication. Consent to use email includes agreement with the following conditions:

• Emails to or from tangata / whānau concerning treatment may be printed in full and made part of tangata / whānau medical record. Because they are part of the medical record, authorised individuals will have access the medical record / email (e.g. billing staff).
• Our clinic may forward emails internally to those involved, as necessary, for healthcare operations and other handling. Our staff will not forward emails to independent third parties without tangata / whānau prior written consent, except as authorised or required by law.
• Although our clinic will endeavour to read and respond promptly to all emails from tangata / whānau, it is not guarantee that any email will be read and responded to within any particular period of time. Tangata / whānau should not use email for medical emergencies or other time‐sensitive matters.
• If tangata / whānau email invites a response from the staff and a response is not received within a reasonable time, it is tangata / whānau responsibility to follow up.
• Please detail any information that tangata / whānau would not like to be communicated over email:
(Tangata / whānau can add to or modify this list at any time by notifying the Clinical Manager in writing.)
Our staff are not responsible for information loss due to technical failures associated with tangata /
whānau email software or internet service provider.


Instructions for communication by email
To communicate by email, tangata / whānau shall:
• Limit or avoid using an employer’s or other third party’s computer.
• Inform the staff of any changes in tangata / whānau email address body
• Take precautions to preserve the confidentiality of emails, such as using screen savers and safeguarding computer passwords.
• Should tangata / whānau require immediate assistance or has serious or worsening condition, tangata / whānau should not rely on email. Instead, tangata / whānau should call the clinic for an appointment or take other measures as appropriate.

Tangata / whanau acknowledgement and agreement
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email between the office and me, and consent to the conditions outlined herein, as well as any other instructions that the office may impose to
communicate with tangata / whanau by email. I acknowledge the staff right to, upon the provision of written notice, withdraw the option of communicating through email. Any questions I may have had were answered.

I accept the above Enrolment Agreement, Email Policy and Privacy Statement.

No SMS/Text Messaging

No Email

Signature: *

Enrol

Personal Information

Emergency Contact

Transfer of Records

In order to get the best care possible, I agree to Te Puna Hauora obtaining my records from my previous Doctor. I also understand that I will be removed from the previous Doctors practice register.

My Declaration of entitlement and eligibility

Proof of Eligibility

1. New Zealand Passport
2. Birth Certificate or Citizenship
3. Or any relevant visas and Passport if not a Citizen

My agreement to the enrolment process:

Enrol

Personal Information

Emergency Contact

Transfer of Records

In order to get the best care possible, I agree to Te Puna Hauora obtaining my records from my previous Doctor. I also understand that I will be removed from the previous Doctors practice register.

My Declaration of entitlement and eligibility

Proof of Eligibility

1. New Zealand Passport 2. Birth Certificate or Citizenship 3. Or any relevant visas and Passport if not a Citizen

My agreement to the enrolment process:

1. New Zealand Passport
2. Birth Certificate or Citizenship
3. Or any relevant visas and Passport if not a Citizen