Dental Pre-authorisation Form

IMPORTANT NOTE: Application forms must be completed in full and submitted either online or via email to authorisation@kaelo.co.za.

For any enquiries, call the Prime Cure Contact Centre on 0861 665 665.
If the benefits are approved, a letter of authorisation will be faxed to the attending dental practitioner within three (3) working days of receiving this form. The following benefits require pre-authorisation: dentures (full / partial / reline / rebase).

Dental Practitioner or Dental Therapist Details

Dental Practitioner *

Postal Address

City

Province

Postal Code

Postal Address

Email *

Council Number

Practice Number *

Telephone

Cell *

Details of Principal Member / Patient

Surname *

First Name *

Email *

Member/Policy Number *

Medical Scheme *

Medical Scheme Option *

Employer

Paypoint No.

Identity Number / Passport *

Gender *

Male

Female

Age

Essential Dentistry and/or Denture Application

(Please provide the tooth numbers and tariff codes)

Teeth worked on

First Name

Surname

ID Number/Passport

Dependant Code

GP Practice Name 1

GP Practice No. 1

GP Practice Name 2

GP Practice No. 2

Procedure/Lab codes *

Tooth Numbers *

ICD-10 Codes *

Add Remove

Lab Practice No.

Lab No.

Co-Payment Value

Receipt No.

Practitioner Signature *

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