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. Fax the documents to 0866 764 374 or email pcauth@mediscor.co.za Dispensing Provider Dispensing Provider Dispensing GP Prime Cure Network Pharmacy: Find a Prime Cure Network povider at www.primecure.co.za Medipost (Courier Pharmacy) Practice Number: 6065732 Please select where the member would like to collect their medication. Doctor Details Referring Doctor * Practice Number * Email * Telephone No. * Fax Cellphone No. Details of Principal Member/Policyholder Surname * First Name * Email * Member/Policy Number * Name of Medical Aid/Health Insurance * Medical Aid/Health Insurance Option Patient Details Surname * First Name * Postal Address * Postal Address Postal Address Postal Address City City Province Province Postal Postal Email * Dependant Code Telephone No. Fax Cellphone No. * Identity Number/Passport * Gender Male Female Age * CDL Chronic Conditions Make a selection * Addison’s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy (COPD) Chronic Obstructive Pulmonary Disease Chronic Renal Disease Coronary Artery Disease Crohn’s Disease Diabetes Insipidus Diabetes Mellitus Type I Diabetes Mellitus Type II Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis (MS) Parkinson’s Disease Rheumatoid Arthritis Schizophrenia Systematic Lupus Erythematosus Ulcerative Colitis OtherOther 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 Weight kg Height m BMI Waist Circumference cm Smoker Yes No Cigarettes per day Allergies Blood Pressure Reading Date Measured Glucose: Date Measured: Random Blood Glucose Fasting Blood Glucose Glucose Tolerance Test (GTT) HbA1c Lipogram: Date Measured Total Cholesterol HDL LDL Triglyceride Creatinine Clearance: Date Measured Creatinine Clearance Result Microalbuminuria Date Measured Microalbuminuria Result Lung Function Date Measured FEV1 FEV/FEC Indicate if the patient has the following Ischaemic Heart Disease/Myocardial Infarction Peripheral Vascular Disease Atherosclerosis Transient Ischaemic Attack/Stroke Date (Ischaemic Heart Disease/MI) Date (Peripheral Vascular Disease) Date (Arteriosclerosis) Date (TIA/Stroke) First degree relative with premature heart disease Female < 65 Years Male < 55 Years 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 www.primecure.co.za. Chronic Condition (eg: Hypertension) * ICD-10 Code (eg: J10) Date of Initial Diagnosis Medicine Name, Strength & Dosage No. of Repeats (If not Ongoing) How long has the Patient used this Medicine? Months Years plus1 Add minus1 Remove Clinical Motivation / Additional Comments Clinical Motivation / Additional Comments * Supporting Documents Drop a file here or click to upload Choose File Maximum file size: 516MB Attach the prescription and supporting documentation (laboratory results or motivation) Doctor's Signature * Clear CAPTCHA Member/ Policyholder Consent Full Name * I,(full name) Identity number * with identity number: consent to the sharing of my clinical information pertaining to my Chronic Medicine Benefit application, and 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 endeavors 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 unauthorized 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. Member/ Policyholder Signature * Clear If you are human, leave this field blank. Submit OR Download Offline Form Rate this item:1.002.003.004.005.00Submit Rating Rating: 3.00/5. From 1 vote. Please wait...
