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Endoscopy Auckland will access Southern Cross’s Provider Portal to apply for prior approval. This may involve disclosure or collection of information
to/from Southern Cross and you acknowledge we have your authority to do so.
Endoscopy Auckland is legally obliged to retain your records for 10 years. After 10 years, if a record has not been used,
it can be disposed of in accordance with the Privacy Act. Would you like your records returned to you in the event of destruction?
Accounts are payable on completion of procedure. Should you default in any payment due to Endoscopy Auckland, ongoing unpaid accounts may
incur collection fees, which will be passed on to the patient:
Please ensure that when you hit the Finish & Submit button that you receive an acknowledgement, otherwise the transmission is not successful.
NB: Fields in RED indicate missing or incorrect information. If information is missing, the form will automatically return you to the field that requires more information.