I intend to use Queenstown Medical Centre as my regular and on-going provider of general practice / GP / health care services.

I understand that by enrolling with Queenstown Medical Centre 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 allow Queenstown Medical Centre to use INZ Visa Verification service to verify my visa conditions if required.

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 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

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 (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 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.

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.

E-mail/Text Messaging
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.

By signing the QMC PHO enrolment form, or by completing the casual/visitor details form, the patient agrees to these terms of trade.

1. In this document:
   1. "You" means any patient or client of Queenstown Medical Centre;
   2. "We", "Us" and "Our" means Queenstown Medical Centre
   3. "Services" means any activity utilising the time and or expertise and or intellectual property of Queenstown Medical Centre staff and /or representatives
   4. "Consumables" means any products supplied to the patient by Queenstown Medical Centre as part of the provided services.
2. Our standard consultation fees are available upon request. Our fees take into account the following factors;
   1. The time spent;
   2. The complexity of treatment;
   3. The costs of running a medical practice;
   4. The funding available from the government, public agencies and other sources.
3. Pre-payments are expected in the following circumstances:
   1. If the patient is enrolled with us, payment is expected at the time of booking regardless of service/procedure type.
   2. If the patient is enrolled with us, payment is expected at the time of booking for any service to be delivered at a cost above that of our standard consultation fee.
4. In cases where pre-payment was not required, or not taken, and/or in cases where additional services have been given above the amount that was pre-paid, all patients are expected to pay in full at the time of their consultation – regardless of enrolment status.
5. If payment is not able to be made at time of consultation payment will be required immediately on receipt of invoice. Accounts outside these terms may be charged an administration fee. Your account may be sent to a debt collection agency if not fully paid in 30 days. We may also:
   1. charge you interest at our banks overdraft lending rate calculated on a daily basis from the date of your consultation until payment; and/or
   2. charge you the cost of recovery for 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
   3. Decline to provide you with further medical services; and/or
   4. Consider changing your enrolment status.

1. 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
2. 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
3. Disclose any information about you and for the purpose of instructing other persons including a debt collecting agency to recover any outstanding fees from you; and

1. All services may attract a fee; and
2. You remain liable for all fees, costs and disbursements (eg. Laboratory testing) charged by us for the services provided not withstanding that these may be recoverable by us from a third party (eg. Insurance providers)

New Zealand Citizens:

• New Zealand Passport (No further documentation required); OR
• New Zealand Driver's License, AND one of the following:
  • Birth Certificate
  • Community Services Card

New Zealand Residents and Other Eligible Persons:

• Passport, AND one of the following:
  • NZ Visa (at least 2 years)
  • Residence Permit

Australian Citizens or Permanent Residents:

• Australian passport, or other passport with Australian permanent resident/resident return visa, AND
• Evidence that New Zealand has been/will be their principal place of residence for at least two years (e.g. employment, house purchase). The two years is counted from their arrival date in New Zealand.