Prime Cure Forms

Please see below links to our forms available online or downloadable.

 

Policyholder / Member Forms

Policyholder / Member Refund Request Form

Please complete the entire form for your refund to be processed.
Please fill in the entire form online or e-mail the completed form as well as your supporting documentation to refunds@primecure.co.za. Your refund will be processed within 14 days of receipt of all the information.

Healthcare Provider Forms

Dental Pre-Authorisation Request Form

Application forms are to be completed in full and submitted either online, via fax: 0866 728 106 or email: dental.preauthorization@primecure.co.za.
For any enquiries call the Prime Cure contect centre on 0861 665 665. Should Benefits be approved, a letter of authorisation will be faxed to the attending dental practitioner/therapist within three (3) working days of receipt of this form. The following Benefits require pre-authorisation: 5th or more amalgam restorations per beneficiary per annum, 5th or more resin restorations (anterior only) per beneficiary per annum and dentures, full/partial/reline/rebase.

Optometry Authorisation Form

Application forms are to be completed in full and submitted either online, via fax: 0866 728 106 or email: optical@primecure.co.za.
For any enquiries call the Prime Cure contect centre on 0861 665 665.

HIV Disease Management Programme Registration

Complete online or download it, complete it and fax / email along with the signed informed consent form, results and script to Prime Cure HIV Department: 0866 49 26 67 or email: hivdmp@primecure.co.za.

CDL Chronic Application Form

To be completed by General Practitioner. Only complete this form for CHRONIC medication for any CDL condition(s) (see section E). Attach the prescription and supporting documentation (laboratory results or motivation), if necessary, to the application. Alternatively download the form to complete and fax the documents to 0866 764 374 or email pcauth@mediscor.co.za.

Radiology Referral Form

Any procedure not listed requires pre-authorisation: this form can be submitted online alternatively contact Prime Cure on 0861 665 665 or email – auth@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

Specialist Referral Form

To be completed by General Practitioner. Any procedure not listed requires pre-authorisation: complete online or contact Prime Cure – 0861 665 665 or Email – auth@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

Pathology Referral Form

Only investigation funded within the Prime Cure Benefit Options will be considered for payment. Please submit the account electronically via your preferred switch. Contact Details: Prime Cure, Private Bag 2108, Houghton, 2041, or 0861 665 665.

Maternity Application Form

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.