Patient Consent: Non-Formulary Medication and Benefits Form

IMPORTANT NOTE: Any procedure not listed requires pre-authorisation: Prime Cure - 0861 665 665 0r 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

Doctor Details

Referring Doctor *

Practice Number *

Email *

Please note that your form submission will be emailed through to this email address.

Telephone *

Fax

Cellphone

Details of Principal Member / Policyholder

Surname *

First Name *

Please note that if you enter the Member's email address in this field then a copy of this form submission will be emailed through to this email address.

Member / Policy Number *

Medical Scheme/Health Insurer *

Medical Scheme/Health Insurer Plan

Employer

Paypoint No

Patient Details

Surname *

First Name *

Patient Address

City

Province

Postal Code

Dependant Code

Telephone

Fax

Cellphone

Identity Number/Passport *

Gender

Male

Female

Age

Patient Requested the Following Non-Formulary Medication

Nappi Code (eg: 791237)

Medication Name (eg: Ventolin Nebules)

Strength (Eg: 25mg)

Add Remove

Patient Agreed to the Following Services Not Covered Under the Benefits

Tariff Code (eg: 791237)

Description (Eg: Ventolin Nebules)

Add Remove

Declaration *

I, the undersigned)declare that I was informed by my doctor that the medication/ investigation/procedure/services fall outside my Prime Cure benefits. I am aware that the medication/investigation/procedure/services will be for my personal account.

Signature *

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