CITY GPS LTD - PATIENT ENROLMENT FORM
PATIENT DETAILS: (All fields marked with * must be completed)

Family Name:*		Given Name[s]:*		
Preferred Name*		Other Name[s]*		
Date of Birth:*		NHI / Chart No.:	/	
Gender:*	 Male	Female	 Other	Country of Birth:*		
If other gender please state:		Place of Birth:*		
Address:*		Postal Address:
(if different from physical address)		

Email:*		
Phone Number/s:*	(h)	(w)	(mob)	
Emergency Contact:		
Relationship:	Contact number:	
Community Services Card:	Y   /  N	Exp:	#:	
Employer and occupation: 		

*Which ethnic group do you belong to?
Tick the space or spaces that apply to you	
▪	New Zealand European		
▪	Maori		
▪	Samoan		
▪	Cook Island Maori		
▪	Tongan		
▪	Niuean		
▪	Chinese		
▪	Indian		
▪	Other (such as Dutch, Japanese, Tokelauan) Please state:	

* I am eligible to enrol in Compass PHO. I choose to use this Practice as my regular and on-going provider of general practice/GP/First Level primary health care services. I am eligible and entitled to enrol because I am residing permanently (residing longer than 186 days per year) in New Zealand and I am a New Zealand Citizen    
OR meet one of the criteria laid out in the Eligibility Guide, with the corresponding letter				

▪	I have read and 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 confirm that if requested I can provide proof of my eligibility
▪	I agree to inform the Practice of any changes in my eligibility.
▪	I understand that by enrolling with this Practice, I will be enrolled with the PHO this Practice belongs to and my name, address and other identification details will be included on both the Practice 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 with the PHO, and their contact details.
▪	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.

OFFICE USE ONLY:
Doctor _______________________  Authorisation: ___________________________________  Date: _____________________  
Evidence sighted/attached:  Y  N  NA      Passport / Driver’s Licence / Other	

Name: _______________________________________________________ Date of Birth: _____________________  

PAYMENT FOR SERVICES
•	City GPs Ltd requires payment for services on the day of your appointment. An accounting fee of $5.00 will be added to your account otherwise.
•	Please understand that failure to attend an appointment or cancelling at short notice may incur a full consultation fee
•	For ease, we welcome individual arrangements for payments for our registered patients, please speak with our receptionist and they will be happy to assist you.
•	If there are any problems with payments we would appreciate you having a discussion with our Practice Manager as to how this can be managed.
•	Failure to pay, or make, suitable arrangements within 60 days may result in debt collection action being taken.

CODE OF CONDUCT

•	City GPs Ltd will treat all people with respect and courtesy at all times.

•	City GPs Ltd has a zero tolerance toward bad behaviour, anyone who is verbally or physically abusive or threatening will be asked to leave the premises immediately and may be de-registered from our practice.

Please sign to indicate understanding and acceptance of the statements on pages 1 and 2:

Signed: ________________________________________________    Date: ______________________________

Authorised Signature [eg. if under 16]:

* Signed Authority: _______________________________________    Date: ______________________________

* Relationship to patient: _____________________________________	Contact phone: __________________________

Page 2

AUTHORITY TO TRANSFER PATIENT NOTES
Date: ____________________  
To whom it may concern,
I/We have now registered with City GPs Ltd for our medical services. I /We authorise the transfer of my/our medical records to City GPs Ltd.
FULL NAME	DOB	SIGNATURE	

OTHER FAMILY MEMBERS WHO ARE TRANSFERRING TO THIS PRACTICE	
FULL NAME	DOB	SIGNATURE (required if 16 or over)	

			

PREVIOUS DOCTOR(s) _____________ _______________________________________________________________
MEDICAL CENTRE ________________________________________________________________________________
MEDICAL CENTRE ADDRESS ________________________________________________________________________
CITY ___________________________________________________________________________________________

We prefer the records transferred by GP2GP transfer please find the details below – City GPs Ltd edi:  citysgwn
Dr Lesley Rothwell	NZMC 8549	Dr Tim Cookson	NZMC 11838	
Dr Clare O'Brien	NZMC 21430	Dr Sarah Sawrey	NZMC 13118	
Dr Tony McNaughton	NZMC 21420	Dr Tim McLeod	NZMC 33185	
If unable to send the records by GP2GP transfer or if you have physical medical records to send, please use the following address:  City GPs Ltd, PO Box 27-348, Wellington 6141 
City GPs Ltd Fax No: 04 381 6160

If you do not receive    pages including this cover page, please contact City GPs Ltd Reception on (04) 381 6161
This facsimile message contains information that is confidential. It you are not the intended recipient; you must not use nor copy the information in any way whatsoever. Please notify us if you have received this facsimile in error by return facsimile or telephone

Page 3

ManageMyHealth (MMH) Registration Form (16 years and older):  	

Please complete and return this section to City GPs:

Full Name: ___________________________________________________   

Preferred Name:_______________________________________________  

Birthdate: ____________________________________________________   

My mobile number is:  (02__ ) ___________________________________

My individual email address is: _____________________________________
NB:  only one person is able to be enrolled per email address

Signature _____________________________________________________	

Date __________________________

Page 
Name: _______________________________________________________ Date of Birth: _____________________  

YOUR PAST MEDICAL HISTORY and YOUR FAMILY HISTORY (please tick all that apply)	
 Family | You 	 Family | You	
		Hypertension		Coronary Heart Disease
	Diabetes		Cancer
	Asthma		Hereditary Illness 
	Allergies	 	Operation(s)
	Significant accidents / injuries  	Long term disabilities
	Any other significant conditions
If you have ticked any of the above, please give further details ____________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________
Smear Test: Date of last smear ______________  	Any abnormal results?	No	Yes  
Mammograms: Date of last mammogram ____________ 	Any abnormal results?	No	Yes  
Immunisations:  Childhood (if under 15) _____________________________________________________________
Date of last tetanus _________  Other immunisations received __________________________________________
_______________________________________________________________________________________________
MEDICATIONS AND ALLERGIES	

Please list any medications you are currently on (including any contraceptive pill) _____________________________
_______________________________________________________________________________________________
Drug allergies (please state)________________________________________________________________________________
LIFESTYLE	
Relationship (please circle)   Single    Married   Separated    Divorced    De Facto  Widow(er)   Same Sex
Number of Children  	 
Smoking Status:
Never Smoked
	Presently smoking - if so, for how many years _________  Daily average _________
 	Ex-smoker – years since quitting _______  How long did you smoke for __________ Daily average __________

Alcohol: 
Do you drink alcohol? 	No	Yes – if so, what is your weekly average __________________________
Exercise:
Do you exercise regularly? 	No	Yes – if so, what______________________________________________

Page 5 

ELIGIBILITY AND ENTITLEMENT GUIDE

To access government funding for your medical care from City GPs Ltd you are required to:
1.	Register with a us
2.	Be enrolled with Compass Primary Health Organisation. To do this you will need to be ‘eligible’ to receive funding by meeting one of the following criteria (please see A to L below):
3.	AND you are required to be ‘entitled’ to receive funding by being resident in New Zealand for more than 186 days in a year [even if you are a New Zealand citizen].

(Please enter the letter that corresponds to you on your enrolment form)
A.	I am a New Zealand citizen OR
B.	I hold a resident visa or a permanent resident visa (previously known as a residence permit) OR
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 OR 
D.	I have a current work visa/permit and can show that I am able to be in New Zealand for at least 2 consecutive years (previous permits included) OR 
E.	I am an interim visa holder who was eligible immediately before my interim visa started OR 
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 OR 
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 
H.	I am 18 or 19 years old and can show that, on the 15 April 2011, I was the dependent of an eligible work permit holder OR 
I.	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) OR
J.	I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme OR
K.	I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund
L.	I am not eligible for further services

Page 6

City GPs Ltd is part of a Primary Health Organisation called COMPASS PRIMARY HEALTH CARE NETWORK.

Contact details for Compass Primary Health Care Network (Wellington Office):
Level 4, 22-28 Willeston Street
Wellington, 6011

(PO Box 27-380)
Wellington. 6011
Ph: (04) 801 7808
Fax: (04) 801 8715
Email: enquiries@compasshealth.org.nz 

Why should you enrol with Compass Primary Health Care Network?
•	You will receive the same services and more to ensure that you and your family stay well and healthy.
•	We can work with other health services in your area to make sure that you and your family receive all the benefits and have access to good quality health care.
•	Lower cost of access to primary health services.

 

I 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 
If I visit another GP who is not my regular doctor I will be asked for permission to share information from the visit with my regular doctor or practice. 
If I have a High User Health Card or Community Services Card and I visit another GP who is not my regular doctor, he/she can make a claim for a subsidy, and the practice I am enrolled in will be informed of the date of that visit.  The name of the practice 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 Practice Enrolment Form will be: 
•	held by the practice 
•	used by the Ministry of Health to give me a National Health Index (NHI) number, or update any changes  
•	sent to the PHO 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. 
Shared Care Record 
Health Information Privacy Statement 

 

 

Wellington

 

Level 

4

, Willeston 

House

 

22

 

Willeston Street,

 

Wellington 6011

 

PO Box 27 380, Marion Square

 

Wellington  6141

 

 

Phone:  

 

04 801 7808

 

Fax: 

 

04 801 8715

 

 

                                                     

 

 

Wairarapa

 

Waiata House 27

-

29

 Lincoln Road

                      

Masterton   5810

 

P

O Box 314

 

Masterton   5840

 

 

                                                       

Phone:

 

06 370 8055

 

                                                       

Fax:

 

06 370 8454

 

 

 

www.compasshealth.org.nz     enquiries@compasshealth.org.nz

 

An electronic summary of my health information will be available to health professionals in hospitals and other settings who are directly involved in my care.  If I do not want my information to be available on the Shared Care Record, I have the option to opt out, or to have specific health information excluded. For more information visit www.scr.org.nz  
Audit 
In the case of financial audits, my health information may be reviewed by an auditor for checking a financial claim made by the practice, 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. 
Health Programmes 
Health data relevant to a programme in which I am enrolled (eg: Breast Screening, Immunisation, Diabetes) may be sent to the PHO 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 PHO 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.
Healthcare Online (ManageMyHealthTM) – City GPs Ltd
This is a web site for you, which uploads patient information from our computer to a secure web server. 
NB: ManageMyHealth™ is now available as an app for your smartphone.  This is downloadable free of charge from the App store.

ManageMyHealth™ is a place where you can access medical information specific to yourself. You can make notes and entries that you may make accessible to practice staff if you wish. We fully support the concept of a patient held electronic health record. 

For us it is a way to have secure electronic communication with you, which can help our medical centre manage the day to day running of our practice. 

IMPORTANT - PLEASE DO NOT USE MANAGEMYHEALTH™ TO COMMUNICATE ACUTE SERIOUS PROBLEMS TO YOUR DOCTOR. PHONE THE SURGERY FOR ADVICE IN THE USUAL MANNER. 
1.	ONLINE APPOINTMENTS 
We encourage you to use the online appointments for bookings. If you will need longer than the standard 15 minutes, please call for a double appointment. 
2.	REPEAT PRESCIPTIONS 
We encourage you to use the Request Prescription service. You will receive an email when your doctor has done the prescription. Please allow 1 working day for this service. If you need a prescription more urgently then phone reception. 
3.	TEST RESULTS 
We would like to use ManageMyHealth™ as one of the ways of notifying you of 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. PLEASE DO NOT SWITCH OFF THE AUTOMATIC NOTIFICATION BOX IN YOUR INBOX SETUP. 
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. 
4.	EMAIL CONSULTATION VIA MANAGEMYHEALTH™ 
Not all doctors or nurses will respond to email requests. The doctors and nurses who don't will send an automatic reply back that you need to phone the surgery for follow-up. 
For simple follow-up queries there is not usually a charge, but there is a charge for more complex queries or queries that are unrelated to a recent consultation. This will vary on the time taken. 
5.	HEALTH SUMMARY
If you see incorrect information in the Health Summary, please contact the practice so we can correct the information. 
6.	MORE SERVICES 
Over time we will be adding more services, eg travel medicine consultation. The fees for services and conditions are in the ManageMyHealth™ site. 
7.	TECHNICAL SUPPORT 
The website is provided by MedtechGlobal, a New Zealand company that provides the software that City GPs uses. They are unable to see your information, as it is encrypted. 

If you are having problems with the website, please go to: http://www.ManageMyHealth™.co.nz/ContactUs/