Maternity Application Form - Prime Cure Health

IMPORTANT NOTE: Any consultation or procedure not listed requires pre-authorisation by calling Prime Cure - 0861 665 665 or emailing maternity@primecure.co.za. 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

Medical Scheme Plan

Member Number

Title

Name

First Name

Surname

Email

Form of Identification

South African ID Number

Passport Number

Identity Number

Passport Number

Date of Birth

Tel

Fax

Cell

Patient Medical History

Height (m)

m

Weight (kg)

kg

Body Mass Index

Have you had a Pap smear?

Yes

No

Date of test

and the results

Do you have a personal or family history of breast, ovarian, or uterine cancer?

Yes

No

Smoker

Yes

No

Average per day

Alcohol

Yes

No

Units per week

Other substance use details

Exercise

Frequency

Hours per week

Type

Intensity

Current Pregnancy Details

Last Menstrual Period

Expected Date of Delivery

Weeks Pregnant

20

Previous Pregnancies (including current pregnancy)

Number of Live Births

Is this a Multiple Pregnancy

Yes

No

Is it:

Twins

Triplets

Have you had any Antenatal Scans?

Yes

No

Were any problems detected?

Yes

No

Specify

Are you currently suffering from any of the following pregnancy induced conditions

Gestational Hypertension

Gestational Diabetes

Mode of Delivery: (planned)

Normal Vaginal Birth

Caesarian Section

Please select indication

Previous Pregnancy Details

Have you ever had a Multiple Pregnancy

Yes

No

Was it

Twins

Triplets

OtherOther

Have you previously had a Miscarriage or a Stillbirth

Yes

No

Please provide details

Gestation at miscarriage/stillbirth

Did you experience any of the following during previous pregnancies

Previous Delivery Details

Normal Vaginal Birth

Yes

No

Number

Did you experience any of the following during a vaginal birth

Caesarian Section

Yes

No

Number

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

General Practitioner's Surname

General Practitioner's Initials

General Practitioner's Practice No.

General Practitioner's Telephone number

General Practitioner's Fax number

Gynae/Obstetrician

Gynae/Obstetrician's Surname

Gynae/Obstetrician's Initials

Gynae/Obstetrician's Practice No.

Gynae/Obstetrician's Telephone number

Gynae/Obstetrician's Fax number

Midwife

Midwife's Surname

Midwife's Initials

Midwife's Practice No.

Midwife's Telephone number

Midwife's Fax number

Declaration

I

First Name

Surname

ID no.

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.

Patient Electronic Signature

Clear

Date

Captcha