Pathology Request Form - Prime Cure Health

Doctor Details

Referring Doctor *

Practice Number *

Email *

Telephone *

Details of Principal Member / Policyholder

Surname *

First Name *

Medical Scheme / Health Insurer *

Medical Scheme / Health Insurer Plan

Email

Member / Policy Number *

Employer

Paypoint No

Patient Details

Surname *

First Name *

Does the patient have the same medical scheme details as the main member?

Yes

No

Medical Scheme / Health Insurer

Medical Scheme / Health Insurer Plan

Member / Policy Number

Dependant Code

Postal Address *

Postal Address

City

Province

Postal Code

Postal Address

Email *

Telephone

Fax

Cell

Identity Number / Passport *

Gender *

Male

Female

Age

Specimen Details

Stat or Routine *

Stat

Routine

Collection Time

Consultation Date

Pathology Practice Name

Practice Number

Clinical Information

Review approved codes here.

Clinical Information *

ICD-10 Code *

Add Remove

Test Selection: The tests listed below do not require Pre-authorisation

Indicate by means of selection, Prime Cure Approved codes only (please see the provider manual for complete list of codes)

A. Chemistry

Cardiac/Muscle

Cardiac Enzymes

CK Total

D-Dimer

Diabetes

Glucose (Random Fasting)

HbA1C

Fructosamine

Glucose Tolerance specimens (4 fasting)

Inflammation / Immune

Complement C3/C4

IgG, IgA, IgM

CRP

Lipids

Lipogram (Random/ Fasting) (For chronic meds application)

Total Cholesterol (For Screening)

Triglycerides

Cerebrospinal fluid

Cell count, Protein, Glucose, Chloride

B. Haematology

C. Endocrine - Reproductive

Reproductive

Thyroid

Thyroid Functions (TSH,T4,T3)

Free T4

Free T3

TSH

Other Endocrine

Cortisol

Alpha feto-protein (AFP)

Carcino-embryonic antigen (CEA) (G.I.T, Lung and Breast)

PSA

CA 19-9 (G.I.T, Pancreas)

CA 15-3 (Breast)

CA 125 (Ovary)

Insulin

D. Serology

Auto-Immune

Rheumatoid Factor

ANF

ANTI – DNA

Arthritis Screen

Hepatitis Tests

Acute Hepatitis (HEP A IgM)

HEP B Immunity (HBsAB)

Acute Hepatitis (HEP A, B)

Chronic Hepatitis (HEP A,B, C)

Hepatitis A,B,C Virus

HIV Tests

HIV Rapid Test

HIV Qualitative screening test

HIV ELISA 1, 2 (Confirmation: Quantitative)

CD 4

Viral Load

E. Microbiology

Microbiology

Urine M,C&S (Incl Culture)

Stool M,C&S (Incl Culture)

Sputum M,C&S (Incl Culture)

Swab/Pus M,C&S

TB culture

ZN Stain/ Acid Fast Stain

F. Cytology

Cytology

Cervical Smear (Normal Consultation)

G. Histology

Biopsy tissue

H. Miscellaneous

Miscellaneous

Downs Screen

Semen Analysis

ACTH

I. SARS COVID-19

SARS COVID-19

GeneXpert MTB/RIF Ultra

PCR

Tariff codes requested that are not part of the benefits:

Tariff codes not part of the benefits will be for the patient’s account.

Signature *

Clear

Application Date *

Copy To

Captcha