Radiology Request Form

IMPORTANT NOTE: Members must be referred by a network GP for out-of-hospital radiology tests. Casualty and in-hospital radiology services require prior authorisation. Contact Prime Cure on 0861 665 665 or send an email to support@kaelo.co.za with your queries. All claims must be submitted electronically to Prime Cure via EDI.

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

Postal Address

Telephone

Fax

Cellphone

Email *

Dependant Code

Identity Number / Passport *

Gender

Male

Female

Age

Authorisation Details

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

Authorisation No.

Authorisation Date

Clinical Information

X-rays and Ultrasound

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

Review approved codes here.

Radiology Request

Procedure Requested

ICD-10 Code

Copy To

Signature

Clear

Application Date

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