Checklist for Patient Registration. (For office use only - aid for Reception staff)

Transcription

1 Checklist for Patient Registration (For office use only - aid for Reception staff) Eligibility to register as an NHS patient checked using flowchart in Patient Registration Procedure AP6 and the Practice Area Map? New Patient Registration form fully completed and signed? NHS Summary Care Record form completed and signed? Vision Online Appointments form completed and signed (Optional)? Please send to IT and Admin Team Carer Information form completed (if applicable)? Appropriate ID and proof of address provided and photocopied? New Patient Welcome letter and Welcome card issued? Practice leaflet given? Nursing Home patient (not including Learning Disabilities)? If yes the additional Nursing Home New Patient Registration Form is required. Please ensure all boxes are ticked when accepting a new registration. Sign below and attach to registration documents. Receptionist Name Date

2 New Patient Registration Pack NEW PATIENT REGISTRATION FORM NHS SUMMARY CARE RECORD... 5 CARER FORM ONLINE APPOINTMENTS FORM... 8 ACCEPTABLE IDENTIFICATION DOCUMENTS FOR REGISTRATION... 9 ENTITLEMENT TO NHS TREATMENT PRIVATE GP FEES FOR OVERSEAS VISITORS PRIVATE MEDICAL SERVICES AND FEES... 12

3 RBHRF001 Page 1 of 4 This form is to register as an NHS patient with Rosebank Health. Please complete the details below in CAPITALS and delete as appropriate at the *. Please bring to either Rosebank or Severnvale Surgery with x1 photo identification and x1 address idenfication (please see page 9 of this pack for more information and for details regarding under 16 s). *Mr / Mrs / Miss / Ms D D M M Y Y Y Y Date of Birth NHS No *Male / Female Surname First Name(s) Previous Surname(s) Town & Country of Birth Home Address Postcode Is this a residential Home? Phone Number: Home Work Mobile Address Ethnic Group (please circle) White UK White European (please specify) Irish Black Caribbean Black African Black Other Indian Pakistani Bangladeshi Chinese Other Ethnic (please specify) First language: English - If No, please specify ) Please help us trace your previous medical records by providing the following information Have you been registered with this practice before? (please circle) Your previous address in UK Postcode Name of previous doctor while at this address Address of previous doctor Postcode If you are from abroad Your first UK address when registered with a GP If previously resident in UK, date of leaving Date you first came to live in the UK If you are returning from the Armed Forces Address before enlisting D D M M Y Y Y Y Service or personnel number Enlistment date If you are registering a child under 5, please tick if appropriate [ ] I wish the child above to be registered for Child Health Immunisations PLEASE SIGN BELOW as *signature of patient or *on behalf of patient Date

4 RBHRF001 Page 2 of 4 NHS Organ Donor registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please circle as appropriate: Any part of Kidneys Heart Liver Corneas Lungs Pancreas Small bowel Tissue my body Signature confirming consent to organ donation For more information, please ask for the leaflet on joining the NHS Organ Donor Register NHS Blood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Tick here if you have given blood in the last 3 years Signature confirming consent to inclusion on the NHS Blood Donor Register D D M M Y Y Y Y Date For more information, please visit the National Blood Service website My preferred address for donation is: (only if different from your current address, e.g. your place of work) Postcode:

5 RBHRF001 Page 3 of 4 Health Questionnaire Please complete the health questionnaire below and return to Rosebank or Severnvale Surgery with the Registration Form. Date of Birth: D D M M Y Y Y Y Surname: First Names: Marital Status: Occupation: Religon: Next of Kin: Relationship: Contact Tel No: Height: Weight: Are you registered disabled?* No / Yes If yes please state type of disability Do you have a carer?* No / Yes Are you a carer?* No / Yes General Medical History (If yes please complete the attached Carer Form) If you are on regular medication, please make an appointment to see a doctor within 2 weeks. You will not be issued any medication before then. What medicines are you taking (including contraceptive pill for females)? Are you on Warfarin? Are you able to administer your own medicines? (If Yes please book an INR appointment and bring your previous INR results with you) Have you any allergies to medicines or anything else? Have you ever smoked? If Yes, are you now an ex smoker? If you are an ex smoker, what year did you stop? If you are a smoker, what is your daily consumption? No of cigarettes: Number of Cigars: Ounces of pipe tobacco: How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week Never Less than monthly Monthly Weekly Daily or almost daily Continued on next page

6 RBHRF001 Page 4 of 4 Please state any specific needs you have so we can ensure they are identified and accommodated for (these include but are not limited too any sensory impairment, use of an Assistance Dog, physical or mental disabilities, access requirements, religious or cultural needs, translator/interpreter requirement, nutritional requirements and phobias): Do you have a Living Will If yes, please bring a written copy to your Registration Health Check Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)? If yes, please state their name / address / phone number: Female patients only *please delete as necessary Have you any children? (give ages) Have you had any miscarriages?* Have you had a termination of pregnancy?* D D M M Y Y Y Y Are you pregnant?* If Yes, date of last period? D D M M Y Y Y Y Have you had a hysterectomy?* If Yes, Date? What method of contraception do you use at present? When was your last cervical smear test? Result? Where taken and by who? Have you ever had an abnormal smear?* D D M M Y Y Y Y Date of last mammogram? Patient Participation Group The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from people about their experiences, views and ideas for making services better. By expressing your interest, you will be helping us to plan ways of involving patients that suit you. It will also mean we can keep you informed of opportunities to give your views and keep you up-to-date with developments within the Practice. If you are interested in getting involved, please tick the box below and we will arrange for the Practice Patient Participation Group Application form to be given to you at your initial consultation. Yes, I am interested in becoming involved in the Practice Patient Participation Group (tick box) Patient signature: Signature on behalf of Patient: Thank you for completing this form Once we have received this form you will be registered at Rosebank Health.

7 Page 5 Summary Care Record OPT OUT FORM YOUR NAME: DATE OF BIRTH: Rosebank Health offers its patients the choice of having a Summary Care Record. The new NHS Summary Care Record has been introduced to help deliver better and safer care and give you more choice about who you share your healthcare information with. What is the NHS Summary Care Record? The Summary Care Record contains basic information about: any allergies you may have, unexpected reactions to medications, and any prescriptions you have recently received. The intention is to help clinicians in A & E Departments and Out of Hours health services to give you safe, timely and effective treatment. Clinicians will only be allowed to access your record if they are authorised to do so and, even then, only if you give your express permission. You will be asked if healthcare staff can look at your Summary Care Record every time they need to, unless it is an emergency, for instance if you are unconscious. You can refuse if you think access is unnecessary. Children under the age of 16 Patients under 16 years will not receive this form, but will have a Summary Care Record created for them unless their GP surgery is advised otherwise. If you are the parent or guardian of a child then please either make this information available to them or decide and act on their behalf. Ask the surgery for additional forms if you want to opt them out. You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. If you are happy for a Summary Care Record to be set up for you then you need take no further action. If you want to opt-out now please tick the box below and return it to Reception as soon as possible. Please sign below if you do not want a Summary Care Record: No I do not want a Summary Care Record Date Signed Hand this form in at your Surgery if you wish to Opt-Out HealthSpace information In addition, patients over 16 can register on a secure website called HealthSpace for a Basic account which gives you access to a Personal Health Organiser. Register at to do this. If you go a stage further you can register for an Advanced account which will entitle you to see a copy of your Summary Care Record once it has been created. Complete the Advanced Registration application and print off the form and contact your Patients Advice and Liaison Service (PALS) office to find out where you should go to register for an Advanced HealthSpace Account. You can do this by ing community.pals@glos.nhs.uk or by telephoning the PALS on Advisers are available Monday to Friday from 9.00am to 5.00pm. When you register you must remember to bring along with you 3 items of identification, Passport and/or Driving Licence and 2 Utility Bills current within the last 3 months. For more information visit either or or call

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9 Page 6 Rosebank Health Carer Identification and Referral Form If you are a Carer or are cared for we would like to hold this information in your medical record. This will help us provide support as necessary and have a better understanding of your needs. By completing this form you agree that we can retain this information in your medical record. Please complete this form and hand it to a member of our Reception team. If you re a Carer who helps and supports someone who can t manage on their own, we want to ensure YOU get all the support YOU need. To be able to do this, we need to know certain facts about your caring situation, as listed in the form overleaf. If you re a carer, with your permission, we will refer you to the Gloucestershire County Council Carers Service, a countywide organisation providing relevant information and advice, local support services, newsletter and telephone help for carers. They are able to assess your needs (called a Carers Needs Assessment) and give you the chance to discuss your role as a Carer and what help you may need to: Support you as a Carer, Maintain your own health Balance caring with other aspects of your life, like work and family, looking at both your current and future needs. It s NOT about judging the way you are caring for someone, nor should social services assume that you wish to become, or carry on being, a Carer. As a result of completing the Assessment, the local authority may provide services to help you in your caring role or to maintain your own health and well-being. It can also look at the needs of the person you care for. This could be done separately, or together, depending on the situation. Carers Details: Your Name: Date of Birth: Section A I AM a Carer Your Address: Home Tel: I care for: Full Name: Mobile: Address: Contact Tel: Date of Birth: Relationship (if any) Is the person you care for registered with Rosebank Health? Yes Please refer me to Care Services for a Carer s Needs Assessment Signed: Date: / No

10 Rosebank Health Carer Identification and Referral Form Page 7 Section B I HAVE a Carer Patient Details: Your Name: Date of Birth: Your Address: Home Tel: I am cared for by: Full Name: Mobile: Address: Contact Tel: Relationship (if any) Date of Birth: Is the person who cares for you registered with Rosebank Health? Yes Are you registered disabled? Signed: 1 Date: / No Agreement by Patient to allow Carer access to their personal details and / or copies of correspondence I give permission for my Carer to have access to my personal details and medical records held by Rosebank Health 1a 1b 1c This Permission relates to all of my Records: This permission relates to a specific condition: Specify the condition: This permission relates to part of my records: Please specify the parts of the record to which access is allowed and any areas specifically excluded: I consent to my Carer receiving copies of all correspondence relating to my treatment I confirm that my GP has sole discretion to withhold any or all information from my carer I understand that this permission will remain in force until cancelled by me in writing and that the doctor may override this authority at any time Signed by Patient: Date: Accepted by Doctor: Date:

11 Page 8 Rosebank Health New online appointments system called Vision Online We have a new optional service called Vision Online. This will let you book and cancel appointments with our practice using the internet. You will need to complete this form to access this service (or if you are already registered with the practice you can complete the application form online) and once registered you will be given information that will enable you to create your username and password. When your account has been created and activated you will be able to book some routine appointments with available doctors, view existing appointments and cancel appointments if required. Please note this service is only available for use by your self. If another member of your family wishes to use this service they will also need to register with a separate address. If you are interested in this service, please complete this form and return it to the practice. We will contact you again in the near future with details on how to fully complete your registration. Forename: Surname: Date of Birth: Address: I confirm I wish to register for Vison Online appointments Patients Signature: Date:

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13 Page 9 Acceptable Identification Documents for Registration at the Practice Please note that you need to provide x2 forms of identification x1 name identification AND x1 address identification Name Identification Current signed full passport Current UK driving licence Blue disabled drivers pass Current benefits or State Pension notification letter confirming rights to benefits for the current period Current HMRC tax notification e.g. PAYE coding, statement of account (P45 s & P60 s are not official HMRC documents) Shotgun or Firearms certificate Travel documents issued to foreign nationals granted permission to remain in the UK Current EU/EEA driving licence Residence permit issued by the Home Office to EU nationals EU/EEA member state identity card Address Identification Recent utility bill or statement showing current address in our area Local Authority tax bill for current year Bank or Building society statements Credit/store card statement Mortgage statement Local Council rent card Tenancy agreement Solicitors letter confirming recent purchase of your property Under 16 s Children under the age of 16 whose Parent/Guardian is registered with the Practice or registering at the same time will need to provide either: Original Birth Certificate or a certified copy Passport If you are unable to provide any of the above documents please speak to a member of the Reception team who will be able to advise alternative documents.

14 Page10 Entitlement to NHS Treatment Please note that in alignment with all Gloucestershire practices, Rosebank Health strictly adheres to the following guidance: Entitlement to free NHS treatment is on the basis of residency regardless of any previous national insurance or tax contributions and irrespective of whether you are a UK passport holder. Holding an NHS number does not indicate that NHS treatment is free of charge. Proof of identity and address will be required (for guidance refer to the attached document Acceptable Identification Documents for Registration at the Practice ). UK Residents If you have established a main residence within our practice area, you are entitled to request to be permanently registered with the practice. UK Citizens living abroad If you live abroad for most of the year you are not entitled to continue to be registered with this practice. Anyone leaving the UK with the intention of living abroad for a period of 90 days or longer must notify the practice of this in advance. If you fall ill when returning on a visit you are entitled to emergency care, if this is deemed necessary by the practice. Insured EEA residents If you do not have a main residence within our practice area you are entitled to any necessary care for chronic conditions, including routine monitoring of existing conditions. This includes the following types of healthcare services for ongoing conditions: blood tests, blood pressure checks, routine maternity care, cholesterol checks, insulin, oxygen, renal dialysis and warfarin tests. Visitors will need to produce their European Health Insurance Card. For the purposes of this guidance, visitors from elsewhere in the United Kingdom can be included within this category. Overseas Visitors (not EEA Residents) If you do not have a main residence within our practice area you do not qualify for free NHS treatment and cannot register with the practice as an NHS patient. The only exception to this is if you need emergency or immediately necessary treatment, which is provided free of charge. The GP will decide if your condition falls into this category. If you wish, you may be treated as a private patient. Registered Asylum Seekers Registered Asylum Seekers are entitled to free NHS services, subject to production of evidence, for the entire term of the application process, including any appeals. Any person who has achieved refugee status is also entitled.

15 Page11 Private GP Fees for Overseas Visitors ( Private fees apply) There is no reciprocal arrangement with these countries and patients can be charged privately. Please see the enclosed list of private services and fees. Country of Origin Private Charges apply Country of Origin Private Charges apply Algeria Jordan Anguilla Kenya Antigua Latvia* Austria* Lebanon Australia Liechtenstein* Bahamas Lithuania* Bangladesh Luxembourg* Barbados Malaysia Belgium* Malta* Bermuda Montserrat Botswana Netherlands* Brazil New Zealand British Virgin Islands Nigeria Bulgaria* Nepal Cambodia Norway* Cameroon Pakistan Canada Poland* Channel Islands Portugal* China Republic of Ireland* Cyprus* Russia Czech* and Slovak Republics Romania* Denmark* Saudi Arabia Dominican Republic Singapore Estonia* Slovakia* Falkland Islands Slovenia* Finland* South Africa France* Spain* Germany* Sri Lanka Ghana St. Helens Gibraltar Sudan Greece* Sweden * Guyana Switzerland* Hong Kong Thailand Hungary* Trinidad and Tobago Iceland* Turkey India Turks and Caicos Islands Indonesia Uganda Ireland United Arab Emirates Iran United States of America Iraq Vietnam Israel Venezuela Isle of Man Yugoslavia (Former) Italy* Zaire Ivory Coast Zambia Jamaica Zimbabwe Japan *EEA Member States (which also include EFTA countries)

16 Page12 Private Medical Services and Fees Not all services at Rosebank Health are available under the NHS. When patients request non-nhs items or services, a private fee may be payable in advance. These fees are listed below. Access to Medical Records Access to paper based records (Data Protection Act) Access to computerised records (Data Protection Act) Photocopy (price per sheet) Certificates and Forms Private sickness or incapacity certificate Private prescription Holiday cancellation certificate Other private certificates and forms Medical Examinations and Reports Driving medicals Sports medical Employment medical and report Employment record extract only Employment report without examination Employment report on proforma Private blood test (per test) Private consultation (per 15 minutes) Fostering medicals (check with Reception) From Travel Vaccinations The following vaccinations will be charged at the following price per person per dose. Prices are correct as of May Vaccination Price Per Dose Number of doses required Hepatitis B per dose 3 4 doses clarify with a nurse Japanese B Encephalitis per dose 2 doses Meningitis ACWY per dose 1 dose Rabies per dose 3 doses Tick-borne Encephalitis per dose 3 doses Whooping Cough (Pertussis) (Travel only is charged also given free on the per dose 1 dose NHS to infants and pregnant women) Travel Vaccinations available free on the NHS These vaccines are free because they protect against diseases thought to represent the greatest risk to public health if they were being brought into the country Tetanus, Diphtheria and Polio Typhoid Hepatitis A Cholera Yellow Fever vaccines are only available from designated centres. Yellow fever vaccines are NOT available from Rosebank and Severnvale Surgeries. 35p