Dental Pre-authorisation Form

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 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

Postal Address
Postal Address
City
Province
Postal Code

Details of Principal Member/Policyholder

Patient Details

Postal Address
Postal Address
City
Province
Postal Code
Gender *

Essential Dentistry and/or Denture Application

(Please provide the tooth numbers and tariff codes)

Teeth worked on

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