Maternity Application Form

Maternity Application Form

IMPORTANT NOTE: Any consultation or procedure not listed requires pre-authorisation by calling Prime Cure - 0861 665 665 or emailing Pre-authorisation number should be recorded on the account to be considered for payment.
Please submit your account electronically using the following destination code - 642P, alternatively post claims to: Prime Cure, Private Bag 2108, Houghton, 2041.

Patient Details

First Name
Form of Identification

Patient Medical History

Have you had a Pap smear?
Do you have a personal or family history of breast, ovarian, or uterine cancer?


Hours per week
Chronic Conditions

Current Pregnancy Details

Is this a Multiple Pregnancy
Is it:
Have you had any Antenatal Scans?
Were any problems detected?
Are you currently suffering from any of the following pregnancy induced conditions
Mode of Delivery: (planned)
Please select indication

Previous Pregnancy Details

Have you ever had a Multiple Pregnancy
Was it
Have you previously had a Miscarriage or a Stillbirth
Did you experience any of the following during previous pregnancies

Previous Delivery Details

Normal Vaginal Birth
Did you experience any of the following during a vaginal birth
Caesarian Section
Please provide reasons for the caesarian delivery
Did you experience any of the following complications after the birth of your children

Medical Practitioner Details

General Practioner




First Name

declare that all the information supplied is to my best knowledge true and correct. I may not hold the Managed Care Company, liable from any of my ommitted information. I consent that the supplied information may be shared amongst contracted health care personnel in order to grant me the best possible care based on approved protocols as per Prime Cure.

I consent to the health care workers responsible for my treatment and/or management in terms of the Programme providing the Programme’s health care workers with the clinical information pertaining to my current pregnancy, and the treatment and management thereof. To the healthcare providers sharing the above-mentioned information with any other health care worker involved with my care or management (including hospital risk management professionals appointed by the Medical Scheme/Health Insurer or the Scheme’s administrator). Provided that no clinical information regarding my health condition will be available to my employer(s) or any other person not involved in my health care, without my express written consent.

I 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 dependents arising from any unintentional unauthorised 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.