Dental Pre-authorisation Form

IMPORTANT NOTE: Application forms are to be completed in full and submitted via this web form, or you can download and complete the offline form and submit to us via fax: 0866 728 106 or email: dental.preauthorization@primecure.co.za.

For any enquiries regarding pre-authorisation, please call Prime Cure on 0861 665 665.
Once your request is processed, if benefits are approved, you will receive a letter of authorisation within three (3) working days of receipt of this form. The following benefits require pre-authorisation:

Five or more extractions
Four or more restorations
Three or more X-rays (maximum 4 per family per annum)
Root canal
Full, partial, reline or rebase dentures
After-hours/out-of-network visits

Dental Practitioner or Dental Therapist Details

Dental Practitioner *

Postal Address

City

Province

Postal Code

Email *

Council Number

Practice Number *

Telephone

Fax

Cell *

Details of Principal Member/Policyholder

Surname *

First Name *

Email *

Member/Policy Number *

Name of Medical Aid/Health Insurance *

Name of Medical Aid/Health Insurance Option *

Employer

Paypoint No.

Patient Details

Surname *

First Name *

Postal Address

City

Province

Postal Code

Dependant Code

Telephone

Fax

Cell

Identity Number / Passport *

Gender *

Male

Female

Age

Essential Dentistry and/or Denture Application

(Please provide the tooth numbers and tariff codes)

Teeth worked on

Procedure/Lab codes *

Tooth Numbers *

ICD-10 Codes *

Add Remove

Lab Practice No.

Lab No.

Co-Payment Value

(A 20% co-payment on the total account, including the laboratory fees is applicable to full and partial dentures)

Receipt No.

Practitioner Signature *

Clear

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