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 this practice I will be
enrolled with the Primary Health Organisation (PHO) this practice belongs to, 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 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 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 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.
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, outside of QMC, 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 outside of QMC,
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 (NHI number, or update any
• 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.
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
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 data relevant to a programme in which I am enrolled (e.g. 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
• health service planning and reporting
• monitoring service quality
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.
Health Information to Private Insurers
I understand that where the cost of service(s) provided by my doctor and/or nurse have been or will
be claimed from a private health insurer that QMC may be required to provide the insurer with
details of the consultation(s) and/or procedure(s) relating to the claim(s) if so requested by the
insurer. I hereby consent to QMC providing this information to such private health insurers.
By agreeing to receive emails or text messages for requests, invitations and notifications and to
participate in health programmes relating to your on-going health care, QMC will not, without your
express instruction email or text any results information. By consenting to us emailing or texting
any information, you accept full responsibility for logical and physical security of your email and
text system and for notifying us of changes to your email address or mobile phone numbers.
Consequently QMC disclaim any responsibility or liability and you agree to indemnify us for
unauthorised access to your email or text messages or unauthorised viewing of information sent by
us. By signing this enrolment form you are acknowledging your responsibilities.
Except as listed above, I understand that details about my health status or the services I have
received will remain confidential within the medical practice unless I give specific consent for
this information to be communicated.
Terms of Trade
1. Our standard consultation fees are available upon request. Our fees take into account the
a) the time spent;
b) the complexity of treatment;
c) the costs of running a medical practice; and
d) the funding available from the government, public agencies, and other sources.
2. We require payment of our fees immediately after your consultation or services provided.
3. If payment is not made immediately, we will invoice you and will 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 interest at our bank’s overdraft lending rate calculated on a daily basis from the
date of your consultation until payment; and / or
b) 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 /
c) decline to provide you with further medical services.
4. In this document:
a) "You" means any patient of QMC;
b) "We", "Us" and "Our" means QMC
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; and
b) 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); and
c) 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
d) send you information about how we may assist you by providing other medical or health services to
You acknowledge that:
a) all services may attract a fee; 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)
New Zealand Citizens:
New Zealand Residents and Other Eligible Persons:
Australian Citizens or Permanent Residents: