Optometry Authorisation Form - Prime Cure Health

Principal Member / Policyholder Details

Surname *

Name *

Initials *

Dependant Code

Occupation

Age

Identity / Passport Number *

Telephone No (Work/Home)

Cell. *

Name of Medical Aid/Health Insurance *

Medical Aid/Health Insurance Option

Member/Policy Number *

Patient Details

Surname *

Name *

Initials *

Dependant Code

Occupation *

Age

Identity/Passport Number *

Telephone No. (Work / Home)

Cell. *

Name of Medical Aid/Health Insurance *

Medical Aid/Health Insurance Option *

Medical Scheme/Health Insurance Number

Declaration by Patient

Full Name *

I the undersigned,hereby confirm that:

I attended the consultation as dated *

I attended the consultation as dated

I was shown the specified range of frames applicable to my optical benefit *

I was shown the specified range of frames applicable to my optical benefit

I am satisfied with the scripts as determined during the consultation *

I am satisfied with the scripts as determined during the consultation

I understand that if I choose a frame or other extras outside the standard benefit, that I am personally liable for the applicable co-payment of *

I understand that if I choose a frame or other extras outside the standard benefit, that I am personally liable for the applicable co-payment ofI understand that if I choose a frame or other extras outside the standard benefit, that I am personally liable for the applicable co-payment of

Co-payment

R

Patient Signature *

Clear

Optometrist Details

Tested by *

Optometrist (Full Name)

Practice Name *

Practice Number *

Fax Number

Email Address

Authorisation No. *

Date of Consultation *

Optometrist Signature *

Clear

Results

Present RX

Sph (Left)

Sph (Right)

Cyl (Left)

Cyl (Right)

Axis (Left)

Axis (Right)

Prism (Left)

Prism (Right)

Base (Left)

Base (Right)

Add (Left)

Add (Right)

VA (Left)

VA (Right)

Unaided VA

Distance (Left)

Distance (Right)

Near (Left)

Near (Right)

New RX

Sph (Left)

Sph (Right)

Cyl (Left)

Cyl (Right)

Axis (Left)

Axis (Right)

Prism (Left)

Prism (Right)

Base (Left)

Base (Right)

Add (Left)

Add (Right)

VA (Left)

VA (Right)

Material

CR39

Glass

P.D. Distance

P.D. Near

SEG. HT. R

SEG. HT. L

Coatings

Tint

Coat

Other

Blank Size

Frame Details:

Mod

Col

Cost

R

Benefit Authorised

Eye Test

Amount Authorised

R

Single Vision Package

Amount Authorised

R

Bifocal Package

Amount Authorised

R

Multifocal Package

(Suremed Only)

Amount Authorised

R

Authorisation No. *

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