Enrolment Form

    Personal Details














    (MAX Size: 3MB. File Types: jpeg, gif, png, pdf)

    Contact Details





    Physical Address*






    Postal Address*






    Emergency Contact / Next of Kin*




    Health details




    Community Services Card



    High User Health Card



    TRANSFER OF RECORDS (NZ ONLY)

    In order to get the best care possible, I agree to Ropata obtaining my records from my previous New Zealand Doctor. I also understand that I will be removed from their practice register



    Dependents

    listed on this form will also be enrolled in the PHO as long as I am legally entitled to sign on their behalf.

























    Ropata Health/Cosine Primary Care Network PHO

    I intend to use Ropata Health as my regular and on-going provider of general practice / GP / First Level primary health care services.

    I am eligible to enrol because I LIVE IN NEW ZEALAND and meet ONE of the following criteria:

    CHOOSE ONE OPTION BELOW:*

    My agreement with Ropata Health/Cosine PHO

    NB: Parent or caregiver to sign if you are under 16 years

    • I choose to enrol with Ropata Health as my regular and ongoing provider of general practice / GP / First Level primary health care services.
    • I understand that by enrolling with Ropata I will be enrolled with Cosine PCN (PHO), and my name, address, and other identification details will be included on both Ropata’s and the PHO Enrolment Register.
    • 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 Ropata and its PHO provides, along with the PHO’s name and contact details.
    • I will be in New Zealand at least 183 days (6 months) in the next 12 months.
    • I have read and I understand the Health Information Privacy 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.
    • I understand that Ropata 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 Ropata. The survey provides important information that is used to improve health services.
    • I agree to inform Ropata of any changes in my contact details and entitlement and/or eligibility to be enrolled.

    PLEASE PROVIDE PROOF OF YOUR ELIGIBILITY TO REGISTER WITH YOUR ENROLMENT FORM (ALL PATIENTS)

    Signature*


    (sign here)*

    Authority*

    Note: An authority is the legal right to sign for another person if for some reason they are unable to consent on their own behalf.





    Authority Address*







    (sign here)*