Chronic Medicine Benefit Application Form

Chronic Medicine Benefit Application Form

IMPORTANT NOTE: This form must be completed by the treating doctor. For a list of approved conditions, please see Section E. Attach the prescription and supporting documentation (laboratory results or motivation), if necessary, to the application and submit online or email

Dispensing Provider

Dispensing Provider
Please select where the member would like to collect their medication.

Doctor Details

Details of Principal Member/Policyholder

Patient Details

Postal Address *
Postal Address

CDL Chronic Conditions

Make a selection *

Patient’s Medical Information

Include copies of the results or reports, both diagnosing and latest where necessary, to prevent delays in the review of this application
Creatinine Clearance:
Lung Function
Indicate if the patient has the following
First degree relative with premature heart disease

Chronic Medication

Prescribe according to the Prime Cure medicine formulary and chronic disease list. Only Medication on the formulary will be covered. The formulary is available for lookup on
How long has the Patient used this Medicine?

Clinical Motivation / Additional Comments

Maximum file size: 516MB

Attach the prescription and supporting documentation (laboratory results or motivation)

Member/ Policyholder Consent

I,(full name)
with identity number:
consent to the sharing of my clinical information pertaining to my Chronic Medicine Benefit application, and the management thereof with Prime Cure. I also consent to Prime Cure sharing my clinical information with any other healthcare professional involved in the management of my condition, including hospital risk management professionals appointed by the Medical Scheme/Health Insurer or the Scheme’s administrator, provided that this information will not be made available to my employer(s) or any other person not involved in my healthcare, or case management, without my express written consent. I acknowledge that whilst Prime Cure shall use its best endeavours to uphold the confidentiality of all information disclosed to it, Prime Cure shall not be held liable for any claims by me or my dependents arising from any unintentional unauthorised disclosure of my personal information, my medical information pertaining to my health condition and the treatment and management thereof to a third party; or as a result of Prime Cure having to use ICD-10 codes when filing a claim for payment with the Medical Scheme/Health Insurer.