The Patient Declaration Form is a crucial document used across New Zealand's healthcare system to establish a formal relationship between healthcare providers and patients. It serves multiple purposes: ensuring informed consent, documenting patient information, and meeting legal requirements under New Zealand healthcare legislation. The form is typically completed upon initial patient registration or before significant medical procedures, capturing essential information about the patient's health status, emergency contacts, and consent for treatment. It includes declarations regarding privacy, information sharing, and financial responsibility, aligned with the Health and Disability Commissioner Act 1994 and Privacy Act 2020. The document is designed to protect both healthcare providers and patients by clearly documenting agreed terms and consents while ensuring compliance with New Zealand healthcare regulations.
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1. Patient Information: Personal details including full name, date of birth, NHI number, contact information, and address
2. Emergency Contact Details: Name, relationship, and contact information for primary and secondary emergency contacts
3. General Health Declaration: Basic health status, existing conditions, current medications, and allergies
4. Privacy Statement: Explanation of how personal health information will be collected, used, and protected in accordance with the Privacy Act 2020
5. Information Sharing Consent: Declaration regarding consent to share medical information with healthcare providers and specified third parties
6. Treatment Consent: General consent for medical examination and treatment, acknowledging right to refuse treatment
7. Financial Responsibility: Declaration regarding payment responsibility and insurance details
8. Truth Declaration: Patient's declaration that all provided information is true and accurate
9. Signature Block: Space for patient signature, date, and witness signature if required
1. Cultural Considerations: Section for patients to specify cultural preferences or requirements regarding their healthcare, particularly relevant for Māori patients
2. Advance Care Directives: Optional section for patients who wish to specify advance directives or living will preferences
3. Interpreter Requirements: Section for patients requiring language interpretation services
4. Research Participation: Optional consent for participation in medical research or clinical trials
5. Alternative Decision Maker: Section for recording details of legal guardian or power of attorney for patients unable to make their own decisions
6. Special Medical Conditions: Detailed section for patients with complex medical conditions requiring specific attention
1. Schedule A - Medication List: Detailed list of current medications, dosages, and frequency
2. Schedule B - Allergies and Reactions: Comprehensive list of known allergies and previous adverse reactions
3. Schedule C - Medical History Summary: Detailed medical history including past surgeries and chronic conditions
4. Appendix 1 - Patient Rights: Summary of patient rights under the Code of Health and Disability Services Consumers' Rights
5. Appendix 2 - Privacy Policy: Detailed privacy policy and information handling procedures
6. Appendix 3 - Financial Terms: Detailed explanation of payment terms, insurance claims process, and financial obligations
Relevant legal definitions
Healthcare Provider
Medical Treatment
Personal Information
Health Information
Consent
Emergency Contact
Next of Kin
Treatment Provider
Medical Facility
NHI Number
Privacy Policy
Advance Directive
Legal Representative
Guardian
Enduring Power of Attorney
Health Services
Clinical Records
Confidential Information
Insurance Provider
ACC
DHB
Informed Consent
Medical Emergency
Treatment Plan
Healthcare Services
Patient Rights
Medical Practitioner
Registered Health Professional
Cultural Support
Whānau
Privacy Breach
Data Protection
Medical History
Disclosure
Adverse Reaction
Medical Treatment
Personal Information
Health Information
Consent
Emergency Contact
Next of Kin
Treatment Provider
Medical Facility
NHI Number
Privacy Policy
Advance Directive
Legal Representative
Guardian
Enduring Power of Attorney
Health Services
Clinical Records
Confidential Information
Insurance Provider
ACC
DHB
Informed Consent
Medical Emergency
Treatment Plan
Healthcare Services
Patient Rights
Medical Practitioner
Registered Health Professional
Cultural Support
Whānau
Privacy Breach
Data Protection
Medical History
Disclosure
Adverse Reaction
Clauses
Personal Information
Privacy
Consent to Treatment
Information Sharing
Financial Responsibility
Emergency Contact
Truth Declaration
Rights and Responsibilities
Medical History
Cultural Considerations
Information Access
Data Protection
Treatment Authorization
Insurance Details
Record Keeping
Confidentiality
Emergency Treatment
Disclosure Authorization
Liability
Declaration of Understanding
Communication Preferences
Payment Terms
Termination of Care
Complaint Process
Research Participation
Privacy
Consent to Treatment
Information Sharing
Financial Responsibility
Emergency Contact
Truth Declaration
Rights and Responsibilities
Medical History
Cultural Considerations
Information Access
Data Protection
Treatment Authorization
Insurance Details
Record Keeping
Confidentiality
Emergency Treatment
Disclosure Authorization
Liability
Declaration of Understanding
Communication Preferences
Payment Terms
Termination of Care
Complaint Process
Research Participation
Relevant Industries
Healthcare
Medical Services
Allied Health
Mental Health
Aged Care
Primary Care
Emergency Services
Private Healthcare
Public Healthcare
Community Health
Rehabilitation Services
Relevant Teams
Administration
Legal
Compliance
Medical Records
Patient Services
Clinical Operations
Quality Assurance
Risk Management
Front Desk
Emergency Department
General Practice
Privacy and Data Protection
Relevant Roles
Medical Director
Practice Manager
General Practitioner
Registered Nurse
Healthcare Administrator
Compliance Officer
Legal Counsel
Medical Records Manager
Patient Services Coordinator
Clinical Risk Manager
Privacy Officer
Quality Assurance Manager
Admissions Coordinator
Emergency Department Director
Healthcare Facility Manager
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