Radiology Request Form

Radiology Request Form

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

Details of Principal Member/Policyholder

Patient Details

Postal Address *
Postal Address
Postal Code

Authorisation Details

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

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