HIV Programme Registration Form

HIV Programme Registration Form

IMPORTANT NOTE: This form must be completed by the treating doctor. Attach the prescription and supporting documentation (laboratory results or motivation), if necessary, to the application and send on this form or via email to hivdmp@primecure.co.za.

Prime Cure Network Doctor Details

Patient Details

Gender *

HIV Medical History

Previous HIV related illnesses/hospitalisations

Other chronic illnesses/hospitalisations:

Clinical Assessment

kg
m
2

HIV Pathology Results

/mm3
%
copies/ml
Hep B sAg

Treating or Allocated Doctor Details

If different to Prime Cure Network doctor details.

Current Regime Requested

Maximum file size: 516MB

Member/Policyholder Consent

I, the undersigned, confirm that:

• I have received individual counselling and education on HIV/AIDS in a language that I understand and that I am able to make an informed decision on joining the Prime Cure Disease Management Programme (“the Programme”)
• The information provided in this application is true and correct and that I voluntarily subscribe to become part of the Programme.
• I understand that the purpose of doing pathology tests is for the ongoing monitoring, clinical management and treatment of my HIV/AIDS condition. These tests must be done for me to continue to be enrolled in the Programme.

I also understand:
• That I may contact Prime Cure for further information and counselling, if required.
• I voluntarily consent to the drawing of blood samples to monitor and treat my HIV/AIDS condition.
• That Kaelo Prime Cure (Pty) Ltd, Registration Number: 1997/017429/07 (“Prime Cure”) is the administrator of the Programme and that any anti-retroviral treatment prescribed, as well as the general management of my HIV/AIDS condition, shall be the sole responsibility of the selected medical practitioners from the preferred provider network of Prime Cure. Prime Cure and my medical scheme (“the scheme”) shall accordingly not be liable for any claims by me or my dependants arising from my participation in the Programme.
• Shall be entitled to terminate my participation in the Programme at any time with immediate effect, but understand that the consequences of such a decision will rest with me alone and that all benefits that I enjoy under the Programme shall then immediately cease and that the scheme shall not be obliged to re-instate such benefits at any time thereafter.
• Acknowledge that should I not comply with the Programme protocols or prescribed treatment that the scheme, at its sole discretion, may elect to exercise its rights to limit benefits to the statutory prescribed minimum benefits.

Consent:
• To the health care workers responsible for my treatment and/or management in terms of the Programme providing the Programme’s Case Managers with the clinical information pertaining to my HIV/AIDS infection, and the treatment and management thereof;
• To the Programme’s Case Managers sharing the above-mentioned information with any other healthcare worker involved with my care or management (including hospital risk management professionals appointed by the scheme or the scheme’s administrator). Provided that no clinical information regarding my HIV/AIDS status will be available to my employer(s) or any other person not involved in my health care, or case management, without my express written consent.
• 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 liable for any claims by me or my dependants arising from any unintentional unauthorised disclosure of my personal information, my HIV/AIDS status, 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 scheme.

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