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 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 * Name First Name First Name Surname 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 Smoker * Yes No Average per day * Alcohol * Yes No Units per week * Exercise Frequency * Hours per week Type * Intensity * LowMediumHigh Chronic Conditions Cardiovascular Endocrine Respiratory Psychiatric HIV OtherOther 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 Pre-Eclampsia Gestational Diabetes Placenta Previa Mode of Delivery: (planned) * Normal Vaginal Birth Caesarian Section Please select indication * Elective Caesarian Previous Caesar Multiple Births High Risk Pregnancy OtherOther 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 * Did you experience any of the following during previous pregnancies Small for Gestational Age Preterm Labour Gestational Hypertension Pre-Eclampsia Gestational Diabetes Placenta Previa Previous Delivery Details Normal Vaginal Birth Yes No Number * Did you experience any of the following during a vaginal birth * Induced Labour Forceps Vacuum Extraction Complications OtherOther Caesarian Section Yes No Number * Please provide reasons for the caesarian delivery * Elective Caesarian Emergency Caesarian Previous Caesar High Risk Pregnancy OtherOther Did you experience any of the following complications after the birth of your children Placental Retention Severe Bleeding Post Partum Infection Breast Feeding Problems Post Natal Depression 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 * I First Name First Name Surname Surname ID no. * declare that all the information supplied is to my best knowledge true and correct.I may not hold Suremed Health or the Managed Care Company liable from any of my omitted information.Do allow that the supplied information may be shared amongst contracted Healthcare 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 Health Care 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. Acknowledge that whilst Prime Cure shall use its best endeavors 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. 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