Radiology Request Form

IMPORTANT NOTE: Any procedure not listed requires pre-authorisation: Prime Cure - 0861 665 665, submit online or send via email to 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.

On submission the completed form will be shown here so that you are able to print it.

Doctor Details

Referring Doctor *

Practice Number *

Email *

Telephone *

Fax

Cellphone

Details of Principal Member/Policyholder

Surname *

First Name *

Member/Policy Number *

Medical Scheme/Health Insurer *

Medical Scheme/Health Insurer Plan

Employer

Paypoint No

Patient Details

Surname *

First Name *

Postal Address *

Postal Address

City

Province

Postal Code

Email *

Dependant Code

Telephone

Fax

Cellphone

Identity Number / Passport *

Gender

Male

Female

Age

Authorisation Details

If applicable, please note that the Authorisation number is only valid for the date of service authorised.

Authorisation No.

Authorisation Date

Clinical Information

X-rays and Ultrasound

Please refer to the GP manual Section 3, Radiology Codes, Page 15 for a list of codes that do not require pre-authorisation.

Radiology Request

Procedure Requested

ICD-10 Code

Copy To

Signature

Clear

Application Date

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