Northland DHB

Please complete this form to apply for access to submit Northland DHB e-Referrals using HealthLink Workplace.

You will be notified by HealthLink once your application is approved and we have activated your login. The process of approval may take three working days.

NB. All users needing access to HealthLink Workplace will need access to a HealthSecure digital certificate. If you don’t have a HealthSecure digital certificate, please contact the Registration Authority on 0800 117 590 or email registration.authority@acc.co.nz.

If your organisation has a ‘site’ certificate, the same digital certificate can be listed for each user.

Application form

Your organisation details

Company name

Trading name (if different from above)

Facility health provider index (hpi) number What's this?

Phone

Fax (Optional)

Street address

Suburb (Optional)

City

Post code

Organisation email address

Primary contact name

Primary contact phone

Primary contact email

Nominated person in your organisation who has approved this request for access

User 1 Details

Preferred username (minimum 8 characters)

First name

Last name

Position/role

Mobile phone (Optional)

Registration number (Optional)

Digital certificate name

[group user-two]

User 2 Details

Preferred username (minimum 8 characters)

First name

Last name

Position/role

Mobile phone (Optional)

Registration number (Optional)

Digital certificate name

[/group]
[group user-three]

User 3 Details

Preferred username (minimum 8 characters)

First name

Last name

Position/role

Mobile phone (Optional)

Registration number (Optional)

Digital certificate name

[/group]
[group user-four]

User 4 Details

Preferred username (minimum 8 characters)

First name

Last name

Position/role

Mobile phone (Optional)

Registration number (Optional)

Digital certificate name

[/group]
[group user-five]

User 5 Details

Preferred username (minimum 8 characters)

First name

Last name

Position/role

Mobile phone (Optional)

Registration number (Optional)

Digital certificate name

[/group]
[group user-six]

User 6 Details

Preferred username (minimum 8 characters)

First name

Last name

Position/role

Mobile phone (Optional)

Registration number (Optional)

Digital certificate name

[/group]

Declarations

I hereby confirm that my organisation has an appropriate Privacy Policy that applies to all employees/contractors and all employees/contractors have been informed of their personal accountabilities to keep health information private.

I hereby confirm that my organisation will be responsible for managing access and contact HealthLink if any changes are required (eg. when staff members leave and no longer require access).

HealthLink Workplace Application Form

Application form

Connecting health providers across New Zealand