Enrolment Form Personal Details Title Mr.Mrs.Ms.MissDr. First Name* Last Name* Preferred Name Other Names Place/Country of Birth* Birth Date* Gender MaleFemaleGender diverse Ethnicity Occupation Is English your first language? YesNo If No, please advise* Photo ID (Drivers Licence OR Passport)* (MAX Size: 3MB. File Types: jpeg, gif, png, pdf) Contact Details Email* Day Phone Night Phone Mobile Phone Physical Address* No. Street name Suburb City Postcode I have a different Postal Address Postal Address* No. Street name or PO Box Suburb City Postcode Emergency Contact / Next of Kin* Name Relationship Phone Health details What is your smoking status? YesNoEx Would you like to go onto the Shared Care Record? YesNo Details of any disabilities you have: Community Services Card Card number Expiry date High User Health Card Card number Expiry date 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 YesNoNot applicable Doctor's Name* Doctor's Surgery Address* Dependents listed on this form will also be enrolled in the PHO as long as I am legally entitled to sign on their behalf. First Name Last Name Gender Ethnicity Date of Birth NHI Number First Name Last Name Gender Ethnicity Date of Birth NHI Number First Name Last Name Gender Ethnicity Date of Birth NHI Number First Name Last Name Gender Ethnicity Date of Birth NHI Number 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:* 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 yearsI 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 startedI 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 traffickingI am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a–fI am 18 or 19 years old and can demonstrate that, on the 15 April 2011, I was the dependant of an eligible work permit holderI 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 Fund. 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* I'm signing for myselfI'm signing as authority for someone else (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. Name Phone Relationship Basis of the authority Authority Address* No. Street Name Suburb City Postcode (sign here)*
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