information sheets managemyhealth enrolment forms nov 2018... · a same day script costs $34. if...

In this pack you will find the following enclosed documents:

Our Team

Information Sheets

ManageMyHealth™

Kauri HealthCare Limited Terms & Conditions

Privacy Brochure

AP Form

Enrolment Forms

New patients can have 30 min PAID appointment with our Health Promotion Co-ordinator.

(this service is optional)

Remember to advise the practice when making the initial appointment.

Should you require any of this information in another language please inform our reception staff.

619 Featherston Street, PO Box 545, Palmerston North 4414

Phone: 06 357 4424 Fax: 06 358 1836

Email: [email protected]

Hours: 7.30am - 7.30pm Monday & Thursday

7.30am –5.30pm Tuesday, Wednesday & Friday

Clinicians accepting patients

P a g e | 1

KHC - Administration - Updated 1 November 2018

Kauri HealthCare welcomes patients moving into the Manawatu from other regions, however we can no longer accept transfers from within the Palmerston North area.

Our Team

KHC Welcome Pack – Our Team_Staff – Version 5 – 1 November 2018

Kowhai

Dr Anna Skinner Dr Tim Ho Dr Sonali Hewage Dr Kathleen Leong Dr Sim Kok Nurse Practitioner : Registered Nurses: Debbie, Dianne, Floss, Julia, Susan Long Term Conditions Nurses: Julia Hince Health Care Assistant: Lucie

Rata

Dr Esther Willis – available for telephone consults only Dr Michael Short Dr Adrian Macquet Dr Su Pothina Dr Paul Tervit Nurse Practitioner: Janice Harrington Registered Nurses: Adele, Barry, Sandra, Stephanie, Vikki Long Term Conditions Nurse: Michelle MacKenzie Sleep Consultant: Jan Leggett Health Care Assistant: Emma

Rimu Roa

Dr Andy Greenway Dr Janine Rasmussen Dr Tim Crowe Dr Miranda Walkinton Nurse Practitioner: Susan Bannister Registered Nurses: Sharyn, Sue, Susan B, Tania, Kelly Long Term Conditions Nurses: Tracey McNeur, Sue Spiers Health Care Assistant: Mel

Receptionists / Administration Staff Alison, Ashleigh, Amy, Barbara, Brenda, Carol, Donna, Elly, Heather, Janine, Jen, Jen, Jo, Liz, Margaret, Michelle, Robin, Robyn, Victoria

Our Team

KHC Welcome Pack – Our Team_Staff – Version 5 – 1 November 2018

Our Staff

All our Kauri HealthCare Staff aim to provide a warm, welcoming and compassionate service to you our patients. We will endeavour to treat you with respect, dignity & independence, free from discrimination. We will do our upmost to provide you with services of an appropriate standard and to communicate effectively with you. While we acknowledge that you may not be feeling your best when you interact with us, we do still expect that you will treat all our staff as you would expect to be treated yourself i.e.

With respect, dignity and free from discrimination Any behaviour that makes our staff feel unsafe will not be tolerated, nor will we accept any behaviour that is disrespectful to our staff including any verbal abuse. All staff members of Kauri HealthCare want the best health outcome for you and your family. Please treat all our staff with respect and courtesy. We look forward to sharing this journey with you and are pleased that you are part of our Kauri HealthCare family.

KHC – General Information

KHC Welcome Pack – General Information - Version 5 - 1 November 2018

Index Operating Hours Appointments Acute Walk-in Clinic After Hours Service TXT2Remind Payment Practice Nurse Service

Specialist Services Immunisations Prescriptions Results Procedure Complaints Suggestions Fees

Your Details

Operating Hours The Practice is open Monday to Friday from 8.00am to 5.30pm for routine doctor appointments. On Monday and Thursday, we run late night clinics until 7.30pm for routine appointments. Our acute Clinic is open from 7.30am – 5.00pm for acute ‘on the day’ appointments only. Routine appointments are 15minutes. Should you require longer than the standard appointment time please advise the receptionist of this when making your appointment. There may be an additional cost for double appointments. If you require medical help outside these hours please contact Healthline on (06) 357 4424 or call ThePalms afterhours service 6pm to 10pm 0800 373 030. In the case of a medical emergency ring 111 or go to the Emergency Department at the Palmerston North Hospital in Ruahine Street.

Appointments Appointments are for 15 minutes. If you need to be seen, please phone as early in the day as possible. If you are unwell and need to be seen urgently or on the same day, you will speak to a nurse who will help assess you and plan a course of action. Expect a wait of 7-10 days for non-urgent appointments. Please tell the receptionist when you ring if you are not sure whether you need a standard appointment. Some problems can be dealt with by the nurse (cheaper for you) or you may need a double appointment. This particularly includes medical examinations for work, insurance, driver’s licences etc.

If you need to cancel an appointment, please let us know as soon as possible so we can give the appointment time to someone else. Failure to do so may result in a fee being charged.

If we have your cell phone number, you will receive a text reminder the day before your appointment.



Acute Walk-in Clinic – Bookings not necessary – check in at reception on arrival Use this service if you require an urgent same day appointment (ie acute) How it works:

You will be triaged by a nurse, usually within 15 minutes of presenting at reception

You will then be seen either by a Doctor or Nurse Practitioner (Note: you may be triaged away or have an appointment made for another day

Patients are seen in priority of urgency ie o Chest Pain o Excessive Bleeding o Severe Pain o Shortness of breath or difficulty breathing

Please advise the staff at reception when you book in if you have any of the symptoms above.

As this is a walk in clinic, THERE WILL BE A WAIT – waiting times are posted in the waiting area, on the wall by the entrance to the clinic.

We charge more for this service as more staff are involved to provide this care to you, to avoid hospital admissions and our patients having to present at other afterhours facilities.

Note: This is an acute on the day service (WINZ certificates do not qualify for this service)

After Hours Service Should you require medical care outside of our hours please contact ThePalms from 6pm to 10pm 0800 373 030. Our doctors do take turns on the roster.

TXT2Remind You will be reminded that you have an appointment for the next day if you supply us with your cell phone number. We are also able to use this facility to contact you regarding your results.

Payment We have a pay on the day policy. Payment can be made by Cash, Cheque, Eftpos, Credit Card and Paywave. If you need to see the Dr or Nurse for several visits i.e. vaccines given over several weeks it may be possible to pay for these at the end of the time. Some of our patients find it easier to set up an Automatic Payment to pay their account off on a weekly or fortnightly basis. Please ask at reception if you wish to use this option. Forms are also included in this pack. Please include your name and chart number in Section C. Alternatively, you can have a portion of your WINZ Benefit redirected to us, to assist in the payment of your account. Any outstanding fees will be sent an account on the 1st of the month via text. If these remain unpaid letters will be sent to you requesting payment. Should no effort be made to clear debts we will then have to contact our debt collector to retrieve payment. Any costs associated with retrieving this debt will be passed on to you. If you are having difficulty paying, please contact the practice. Even a small regular amount – eg $5 weekly – can often cover the cost. Please also refer to KHC – Terms and Conditions All new patients and casual patients must pay for their initial visits to Kauri HealthCare.



Practice Nurse Service We are trying to reduce your health costs – our Registered Nurses can do a lot! Fees: $30 for a standard nurse consultation. An extra fee is charged for materials used and long consultations.

Please ask for a Nurse Appointment for the following: Well Health Checks (men at 45 and 60, women at 50) Routine Vaccinations Cervical Smears Bladder Infections Blocked Ears Warts Routine checks of Blood Pressure, asthma Dressing changes General Health advice Cardiovascular Risk Assessment Sexual Health Checks (may be free) Smoking Cessation – Ask to see the Smoking Cessation Coordinator

Our Health Care Assistants are also available and can do Blood Pressures, Urine tests and ECG’s amongst other things. They work closely with our Registered Nurses

Please ask to see the Nurse then the Doctor for the following: Medicals for Insurance / Employment / Drivers’ Licenses / Medical examinations, ‘Full Health Checks”, 6 week immunisations, new patient checks, refugee appointments

Immunisations There is a series of immunisations that children can have from 6 weeks of age. Book an appointment with a Registered Nurse. Our Long Term Conditions Nurse Team see patients with long term health problems. This is a group of highly trained Registered Nurses and they work within your health care team. Some of the things they do: Annual reviews for diabetics Comprehensive health assessments Group sessions for pre diabetics Winter wellness plans for people with chronic chest problems Commence diabetic patients on insulin … And many more



Specialist Services Healthy Sleep Clinic Provides help for people who have sleep difficulties such as:

Sleeping at wrong times of day so unable to sleep at night

Disturbed sleep following overseas travel

Waking feeling tired & unrefreshed,

Daytime fatigue from poor sleep

Paediatric sleep problems,

Primary Insomnia

Chronic Insomnia

Restless legs

Parasomnias

Shift work

Snoring

Jet lag

Help to stop benzodiazepines & other sleep medications.

Cost: First Appointment $120.00 Subsequent Appointments $60.00 Phone our practice or email: [email protected] Other specialist services include: IUD Insertions Skin Checks Minor Surgery Elder Health

Prescriptions Repeat prescriptions are given at the discretion of the GP or Nurse Practitioner. Repeat phone prescriptions can be done and either collected or faxed through to a Pharmacy. Routine prescriptions cost $18, allow 2 working days for completion. A same day script costs $34. If you are collecting the script it will be available after 4pm that day, if ordered in the morning. Note: We do not charge you to fax your script through to your Pharmacy, however some Pharmacies do charge to receive scripts this way. When you request a script please give a list of each medication you need, your name, DOB and phone number.

Results Procedure We will only contact a patient if they have an abnormal result. The nurse will phone back at a time that is suitable to them. If you would like to discuss your results with a GP or a Nurse Practitioner, it may be possible to organise an appointment for a phone consult with your doctor, there will be a charge for this. OR Consider enrolling with ManageMyHeath™ our online patient portal, then you will be able to access your results online. See further information in Manage My Health section

mailto:[email protected]



Complaints You are encouraged to let us know if you have a complaint. If you are unhappy with the way something has been handled or treatment you have received please discuss it with a doctor, one of the staff, or send us a written complaint. Please refer to your rights under the Health and Disability Code. Our staff will provide you with the relevant pamphlet. If you find it difficult to bring it up in person please write it down and send it to us. We have a standardised form for complaints, which we would prefer you to complete. If you mark the envelope "Confidential" only the addressee will open it. All complaints will be responded to within 10 working days. Complaint forms are available in the practice or you can ask for a form to be completed on your behalf by a Kauri HealthCare team member.

We take your complaints very seriously.

Suggestions We always try to offer you the best service that we can therefore we would appreciate hearing from you if you have any suggestions regarding your experiences with us. Please feel free to complete a form and drop it into the Suggestions Box at reception. We do welcome your feedback, this kind of information enables us to work towards a better quality service.

Fees Some of our charges have already been mentioned, however the following fees apply for a standard consultation: General Practitioner / Nurse Practitioner Acute Clinic Appointments

Adult 18+ $44 $54 Children 13-17 $40 $50 Children under 13yrs Free Free Registered Nurse Consultations: $30 Health Care Assistant Consultations $10 - $15 (depending on procedure) All fees are displayed in the practice and are subject to change at any time.

Your Details Should any of your details change while you are registered with us we need to know to keep our records up to date. So please advise us if you:

Change your residential address, email address, phone numbers or other contact details

Change your name by marriage or deed poll Have a change of employment Have new Community Services Card details (including Gold Card)

Manage My Health

KHC Welcome Pack- Manage My Health –Version 4 – 1 November 2018

ManageMyHealth™ ManageMyHealth™ is a web site for you; it uploads your information from our computer to a secure web server. It is a place where you can access your health information online, it’s easy and confidential. We fully support the concept of a patient held electronic health record. For us, it is a way to receive secure electronic messages from you, which will help us manage the day to day running of Kauri HealthCare. THIS IS A NON-URGENT SERVICE. PLEASE DO NOT USE MANAGEMYHEALTH™ TO COMMUNICATE ACUTE SERIOUS PROBLEMS TO YOUR DOCTOR. PLEASE PHONE 111 IN THE C ASE OF AN EMERGENCY OR US ON (06) 357 4424 FOR ADVICE ON URGENT MATTERS.

Repeat Prescriptions We encourage you to use the Request Prescription service. This service is only available for medications you are on long term. The script can be either faxed to your pharmacy of choice or it can be collected. You will receive a Manage My Health™ email informing you when your script has seen by your GP, please wait for a text from us to let you know when it is ready to be collected or has been faxed. For all routine prescriptions allow 2 working days for them to be completed. Test Results We would like to use ManageMyHealth™ as one of the ways of notifying you of your test results. We also use texting and telephone. When we file a result you will be sent an email saying your record has been updated. We recommend you do not switch off the automatic notification box in your inbox setup, so you can receive these messages. Your 'Lab Results' section in the 'Health Summary' option will have your results. One column has your doctor’s comments on the test. For more detail click the blue 'i' button. Please read your doctor's comments and take any action recommended. If there are serious abnormalities we will endeavour to contact you through other channels, including phone and letter. Email Consultations via ManageMyHealth™ By agreeing to use this service you agree to pay the associated fee within 7 days after the consultation is completed. Your doctor or recipient of your request has sole discretion as to when a consultation is completed and billed. For queries or complaints please contact Kauri HealthCare. This service is not intended to replace face-to-face consultations. We will respond to your request within two working days. The advice provided by your doctor is limited by the information you provide and the information we already have in our records. If your request is too complex you may be asked to make an appointment for a consultation. Health Information If you see incorrect information in the Health Summary, please contact Kauri HealthCare so we can correct the information or you can update on your Manage My Health account™. Appointments All standard appointments are 15 minutes and will incur a standard consultation fee which is to be paid on the day of appointment. We will send you a ManageMyHealth™ email once your appointment has been accepted. Cancellations must be made at least one working day before the confirmed appointment. Failure to attend the appointment or cancellations within 24 hours of the appointment will incur a fee. If you require an appointment with the nurse or a longer appointment, please phone the practice on 06 357 4424.

Manage My Health

KHC Welcome Pack- Manage My Health –Version 4 – 1 November 2018

General Conditions All messaging services are non-urgent services and we will attempt to answer your query within two days. Misuse of our ManageMyHealth™ service will result in suspension of your ManageMyHealth™ account. A separate email is required for each person signing up to Manage My Health™, parents can also sign up their children and manage the email account until the child reaches the age of 17 when Manage My Health™ will contact them to see if they wish to take over their account. All children must have a separate email address as well. Technical Support The website is provided by MedtechGlobal, a New Zealand company that provides the software that Kauri HealthCare Limited uses. MedtechGlobal is unable to see your information, as it is encrypted.

KHC - Terms and Conditions

KHC – Welcome Pack – Terms and Conditions – Version 4 – 1 November 2018

PATIENT ADVOCACY Should you have a complaint about the quality of our service we encourage you to bring it to our attention as soon as possible. Kauri HealthCare maintains an active consumer complaint process alongside our clinical and organisation quality and risk processes. You may lodge your complaint by contacting any of our staff. Kauri HealthCare supports the promotion and protection of the rights of health and disability consumers. Therefore should your complaint not be satisfactorily resolved we encourage you to contact the Health and Disability Advocacy service, by contacting them on 0800 555 050 or by emailing [email protected].

The Health and Disability Commission web site at www.hdc.org.nz has further information on your rights as a health consumer. The service aims to assist consumers to achieve consumer-centred health and disability services and resolution of complaints. Independence, accessibility, confidentiality and ethical practices are key components of the services.

HEALTH INFORMATION PRIVACY STATEMENT We adhere to the following Central Primary Health Organisation Health Information Privacy Statement. In acknowledging you have read and agree with the Health Information Privacy Statement you confirm that you understand the following.

Access to my health information I have the right to access (and have corrected) my health information under Rules 6 and 7 of the Health Information Privacy Code 1994.

Visiting another GP Practice If I visit another GP who is not my regular GP I will be asked for permission to share information from the visit with Kauri HealthCare. If I have a High User Health Card or Community Services Card and I visit another GP who is not my regular GP, he/she can make a claim for a subsidy, and Kauri HealthCare will be informed of the date of that visit. The name of the GP I visited and the reason(s) for the visit will not be disclosed unless I give my consent.

Patient Enrolment Information The information I have provided on the Patient Enrolment Form will be:

- held by Kauri HealthCare - used by the Ministry of Health to give me a National Health Index (NHI) number, or update

any changes - sent to the Central Primary Health Organisation and Ministry of Health to obtain subsidised

funding on my behalf - 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.

Health Information Members of my health team may:

- add to my health record during any services provided to me and use that information to provide appropriate care

- share relevant health information to other health professionals who are directly involved in my care.

Audit In the case of financial audits, my health information may be reviewed by an auditor for checking a financial claim made by Kauri HealthCare, but only according to the terms and conditions of section 22G of the Health Act (or any subsequent applicable Act). I may be contacted by the auditor to check that services have been received. If the audit involves checking on health matters, an appropriately qualified health care practitioner will view the health records.

mailto:[email protected]

http://www.hdc.org.nz/



Health Programmes Health data relevant to a programme in which I am enrolled (e.g. Breast Screening, Immunisation, Diabetes) may be sent to the Central Primary Health Organisation or the external health agency managing this programme.

Other Uses of Health Information Health information which will not include my name but may include my National Health Index Identifier (NHI) may be used by health agencies such as the District Health Board, Ministry of Health or Central Primary Health Organisation for the following purposes, as long as it is not used or published in a way that can identify me: - health service planning and reporting - monitoring service quality payment.

Research My health information may be used for health research, but only if this has been approved by an Ethics Committee and will not be used or published in a way that can identify me.

Except as listed above, I understand that details about my health status or the services I have received will remain confidential.

The practice participates in a national survey about people’s healthcare experience and how their overall care is manage. Taking part is voluntary and all responses will be anonymous. Patients can decline the survey or opt out by informing the practice. The survey provides important information that is used to improve health services. TERMS OF SERVICE

Our standard consultation fees are available upon request and maybe adjusted from time to time. Our fees are GST Inclusive and take into account the following factors:

a) the time spent; b) the complexity of treatment c) the cost of materials, equipment, staff and overheads d) funding available from the government, public and other sources

1. We require payment of our fees immediately after your consultation or service provided. We accept debit and credit cards, paywave and payment by cash and cheques.

2. If payment is not made immediately, we will invoice you and may charge you an administration fee for doing so. Your account may be sent to a debt collection agency if not fully paid within 30 days. We may also:

a) charge you the cost of recovery of the outstanding fees and interest including our legal costs on a solicitor/client basis, any court costs and disbursements, service or collection fees; and / or

b) require you to agree to a payment plan, including automatic payments c) decline to provide you with further health services - except in the case of an emergency

3. Prices quoted for services may be adjusted from time to time, and the customer agrees to pay any such adjusted price.

4. Any accounts outstanding at month end incur an administration fee of $5.00. 5. Interest may be charged on overdue accounts at a rate to be decided by Kauri HealthCare. 6. No goods supplied by Kauri HealthCare may be returned for credit. 7. Supply of goods for personal use will be covered by the Consumer Guarantees Act. 8. In this document:

a) “You” means any patient of Kauri HealthCare and b) We”, “Us” and “Our” means Kauri HealthCare



9. You authorise us to: a) make enquiries with any previous medical practitioners and health professionals you may

have engaged regarding your medical history and you authorise disclosure by those people to us

b) send you information about how we may assist you by providing other medical or health services to you

c) make enquiries with from time to time with credit agencies regarding your credit history and to release information from time to time to the extent where necessary for the purpose of making such enquiries (and you authorise disclosure by those agencies to us);

d) disclose any information about you for the purpose of instructing other persons including a debt collecting agency to recover any outstanding fees from you; and

10. You acknowledge that: a) All services may attract a fee unless clearly stated otherwise; and b) you remain liable for all fees, costs and disbursements (e.g. laboratory testing) charged by us

for the services provided notwithstanding that these may be recoverable by us from a third party (e.g. insurance providers)

KHC Welcome Pack – Privacy Brochure – Version 4 – 01 November 2018

Kauri HealthCare Limited 619 Featherston Street, Palmerston North 4414

P O Box 545, Palmerston North 4440 Telephone: 06 357 4424, Fax 06 358 1836

Privacy brochure for patients Our practice follows the rules set out below whenever we collect, use, store or disclose information about your health.

Collecting your health information

When we collect health information from you we will:

o only collect the information for the purpose of treating you (or for some related purpose);

o collect the information directly from you unless you have authorised us to collect the information from someone else (or we have some other lawful reason for collecting the information from someone else); and

o tell you why we are collecting the information and what we will do with it. Using your health information

We will not use your health information for any purpose other than for the purpose of treating you unless we get your consent or we will use your information in a way that doesn’t identify you (or where we have some other lawful reason for doing so). Storing your health information

We will store your health information securely so that only authorised people can access or use your information. Disclosing your health information

We will not disclose your health information to anyone without your consent unless we have a lawful reason for doing so. Access and correction of your health information

You can ask us to confirm whether we hold information about you. If we hold information about you, you have the right to access the information. You can ask us to correct any information that we hold about you if you think that the information is inaccurate. If we refuse to correct your information, you can ask us to put a note on your information that states that you have asked for the correction to be made. Enquiries

If you have any concerns about any matter relating to your health information, please ask to speak to our privacy officer.

All Kauri HealthCare staff are bound by these privacy issues.

Enrolment Process

As part of the Kauri HealthCare enrolment process, we require all new patients to meet with our Health Promotions Co-ordinator to allow you to go through your notes and to ensure that we have the correct information on file for your new doctor. This appointment is 30 minutes long and you will be charged $30.00. Patients have found this consult helpful, as it highlights to the doctor what your initial concerns are as well as allowing us to document your medications (please bring your medications to this appointment).

This check will also include an introduction to Kauri HealthCare, the services available to you, a health check and a brief discussion on self-management (Manage My Health™). This is an electronic portal which allows you to get a copy of your test results, request repeat prescriptions, making appointments as well as giving you the opportunity to talk to your doctor about any health concerns.

Signature Date

Please return this form along with your enrolment form and the new patient information sheet also included in this pack.

KHC Administration – Enrolment Process – Version 1 – 1 November 2018

KHC Enrolment Form- updated 1 November 2018

KAURI HEALTHCARE - PATIENT ENROLMENT FORM

Patient details: All fields Must be completed

EDI number: vaa3ifhc

Doctor: NZMC:

NHI (Office use only)

Name

(Title) Given Name Other Given Name(s)) Family Name

Other Name(s) (eg. maiden name)

Maiden name

Birth Details

Day / Month / Year of Birth Place of Birth Country of birth

Gender Occupation Male FemaleGender diverse (please state)

Usual Residential Address

House (or RAPID) Number and Street Name Suburb/Rural Location Town / City and Postcode

Postal Address (if different from above)

House Number and Street Name or PO Box Number Suburb/Rural Delivery Town / City and Postcode

Contact Details

Mobile Phone Home Phone Email Address

Emergency Contact

Name Relationship Mobile (or other) Phone

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 records No transfer Not applicable

Previous Doctor and/or Practice Name Address / Location

Ethnicity Details Which ethnic group(s) do you belong to?

Tick the space or spaces which apply to you

New Zealand European

Maori

Samoan

Cook Island Maori

Tongan

Niuean

Chinese

Indian

Other (such as Dutch, Japanese, Tokelauan). Please state

Iwi (if applicable):

Community Services Card

Yes

No Day / Month / Year of Expiry

Card Number

Smoking Status:

Current Smoker Never Smoked

Ex-Smoker <12mths Ex-Smoker >12mths

If Current Smoker: The best advice we can give you for your health and well being is to quit smoking, here at Kauri Health Care we can help you on your journey to wellness, please tick if you would like to be contact for support to quit smoking.

Yes I would like to be contacted

No, I would not like to be contacted at this time – you may be asked again in the future

Primary Health Services Provider Enrolment Form


My declaration of entitlement and eligibility

I am entitled to enrol because I am residing permanently in New Zealand.

The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months

I am eligible to enrol because:

a I am a New Zealand citizen (If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)

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

b I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)

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

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)

e I am an interim visa holder who was eligible immediately before my interim visa started

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

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

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)

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

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

I confirm that, if requested, I can provide proof of my eligibility Evidence sighted (Office use only)

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 on-going provider of general practice / GP / health care services. I understand that by enrolling with Kauri Healthcare will be included in the enrolled population of Central PHO and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers. I understand that if I visit another health care 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 along with the PHO’s name and contact details. 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. 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 contact details and entitlement and/or eligibility to be enrolled.

Signatory Details Signature Day / Month / Year Self Signing Authority

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

Authority Details

(where signatory is not the enrolling person)

Full Name Relationship Contact Phone

Basis of authority (e.g. parent of a child under 16 years of age)


KAURI HEALTHCARE - PATIENT ENROLMENT FORM

Patient details: All fields Must be completed

EDI number: vaa3ifhc

Doctor: NZMC:

NHI (Office use only)

Name

(Title) Given Name Other Given Name(s)) Family Name

Other Name(s) (eg. maiden name)

Maiden name

Birth Details

Day / Month / Year of Birth Place of Birth Country of birth

Gender Occupation Male FemaleGender diverse (please state)

Usual Residential Address

House (or RAPID) Number and Street Name Suburb/Rural Location Town / City and Postcode

Postal Address (if different from above)

House Number and Street Name or PO Box Number Suburb/Rural Delivery Town / City and Postcode

Contact Details

Mobile Phone Home Phone Email Address

Emergency Contact

Name Relationship Mobile (or other) Phone

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 records No transfer Not applicable

Previous Doctor and/or Practice Name Address / Location

Ethnicity Details Which ethnic group(s) do you belong to?

Tick the space or spaces which apply to you

New Zealand European

Maori

Samoan

Cook Island Maori

Tongan

Niuean

Chinese

Indian

Other (such as Dutch, Japanese, Tokelauan). Please state

Iwi (inapplicable):

Community Services Card

Yes

No Day / Month / Year of Expiry

Card Number

Smoking Status:

Current Smoker Never Smoked

Ex-Smoker <12mths Ex-Smoker >12mths

If Current Smoker: The best advice we can give you for your health and well being is to quit smoking, here at Kauri Health Care we can help you on your journey to wellness, please tick if you would like to be contact for support to quit smoking.

Yes I would like to be contacted

No, I would not like to be contacted at this time – you may be asked again in the future

Primary Health Services Provider Enrolment Form


My declaration of entitlement and eligibility

I am entitled to enrol because I am residing permanently in New Zealand.

The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months

I am eligible to enrol because:

a I am a New Zealand citizen (If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)

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

b I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)

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

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)

e I am an interim visa holder who was eligible immediately before my interim visa started

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

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

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)

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

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

I confirm that, if requested, I can provide proof of my eligibility Evidence sighted (Office use only)

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 on-going provider of general practice / GP / health care services. I understand that by enrolling with Kauri Healthcare will be included in the enrolled population of Central PHO and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers. I understand that if I visit another health care 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 along with the PHO’s name and contact details. 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. 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 contact details and entitlement and/or eligibility to be enrolled.

Signatory Details Signature Day / Month / Year Self Signing Authority

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

Authority Details

(where signatory is not the enrolling person)

Full Name Relationship Contact Phone

Basis of authority (e.g. parent of a child under 16 years of age)

REQUEST TO TRANSFER MEDICAL RECORDS

All patients over the age of 16yrs must sign their own consent to transfer medical files

EDI: vaa3ifhc

Kauri HealthCare 619 Featherston Street

PO Box 545 Palmerston North 4440

P: +64 6 357 4424 F: +64 6 358 1836

Patient Name:……………………………………………………………………………………………………………………………

Date of Birth:…………………………………………….. NHI #:………………………………………………

Patient Name:………………………………………………………………………………………………………………………….

Date of Birth:…………………………………………….. NHI #:………………………………………………

Patient Name:……………………………………………………………………………………………………………………………

Date of Birth:…………………………………………….. NHI #:………………………………………………

Request that my medical records be transferred from:

Previous Medical Centre:…………………………………………………………………………………………………………..

Address:……………………………………………………………………………………………………………………………………

Fax:…………………………………………………………… OR

Email:………………………………………………………………………………………..

Signature:………………………………………………………………….. Date:………………………

New Patient Information Sheet

KHC Administration – NP Information Sheet – Version 1 – 1 November 2018

This form is to be completed by new patients joining Kauri HealthCare. It is vitally important that we have accurate and current information to ensure best practice. Your Practitioner will be:

Marital Status Single Married De Facto Spouse

Separated Divorced Widowed

Names of Dependant Children Date of Birth Vaccination History

Date: Surname: First & Middle: Preferred Name: Gender: Male Female

Address: Ethnicity: Residential Status: NHI: CSC number: Pharmacy:

Phone: Day Night

Mobile Phone Number: Email:

Date Of Birth: Place Of Birth:

With whom do you live?

Occupation: Employer: Phone:

Next of Kin Details: Name: Relationship: Phone Home: Address: Work: Mobile:

Please bring in Plunket books for all children aged 11 or under.



This form is to be completed by new patients joining Kauri HealthCare.

Medical History You Family member

Yes/No Yes/No

Have you or any member of your family ever had asthma, used an inhaler medication or been troubled by shortness of breath?

Do you or any member of your family have diabetes or raised blood sugar levels?

Have you or any member of your family ever had epilepsy, experienced fits, seizures, convulsions, fainting or blackouts?

Have you or any member of your family ever had heart disease, heart murmur or irregular heartbeat?

Do you experience chest pain or angina?

Have you or any member of your family ever had or been told that you have high blood pressure?

Have you ever had injuries that have led you to see a doctor, physiotherapist or chiropractor?

Have you or any member of your family ever been diagnosed with hepatitis, HIV, or Aids?

In the past two years, have you suffered from migraines or persistent headaches?

Have you ever consulted a psychiatrist or psychologist?

Have you or any member of your family ever suffered from mental illness, depression, anxiety or stress?

Have you or any member of your family ever been diagnosed with any form of cancer, including skin cancer?

Have you or any member of your family ever suffered from arthritis or any bone or joint problems?

Are you currently receiving treatment for any health conditions?

Do you or should you wear glasses or contact lenses?

Do you have trouble hearing?

Have you had any operations?

Have you been in hospital for any other illness?

Have you ever seen a specialist about any other problems?

Have you ever had any specialist’s tests: i.e. barium meal, gastroscope, cardiograph?

Do you have any long-term illness or disability: i.e. raised BP, skin complaint, diabetes, asthma?



Lifestyle Do you smoke now? Yes/No number per day:

Have you ever smoked? Yes/No gave up in

How much alcohol do you drink? Per Day: Per Week:

How often do you engage in regular exercise? (eg active gardening, brisk walking, dancing – for at least 30 minutes)

Times per week:

Women Number of Children Year born:

Pregnancy history (Caesar, miscarriage etc)

Form of contraception (if relevant)

Date of last cervical smear Date:

Date of last mammogram Date:

If you answered Yes to any of the questions above please provide details: Please list any current medications?

Are you Allergic to any medications / food? Yes No If Yes please give details:

Immunisations History i.e. Tetanus, Hepatitis

information sheets managemyhealth enrolment forms nov 2018... · a same day script costs $34. if...

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