Specialist Referral Form

IMPORTANT NOTE: To be completed by the referrring Prime Cure Network doctor. Any procedure not listed requires pre-authorisation. Contact Prime Cure 0861 665 665 or email authorisation@kaelo.co.za. The pre-authorisation number must be recorded on the account for it to be considered for payment. Please submit your account electronically via EDI.

Doctor Details

Referring Doctor *

Practice Number *

Email *

Telephone *

Fax

Cell

Details of Principal Member

Surname *

First Name *

Employer

Paypoint No

Member Number *

Medical Scheme/Health Insurer *

Medical Scheme/Health Insurer Plan

Patient Details

Surname *

First Name *

Postal Address *

Postal Address

City

Province

Postal Code

Postal Address

Telephone

Fax

Cell

Dependant Code

Identity Number/Passport *

Gender

Male

Female

Age

Reasons for Referral

Diagnosis/Suspected Diagnosis *

Motivation for Referral *

ICD-10 Code *

Date of Onset *

Date of Diagnosis *

Specialist Practitioner’s Details

Specialist Name *

Practice Number *

Telephone

Fax

Cell

MP No.

Consultation Date

Authorisation No.

Authorisation Date

Concomittant Medication - Patient Current Medication

Diagnosis (eg: Hypertension)

ICD-10 Code (eg: J10)

Medicine Name

Strength (eg: 25mg)

Frequency of Administration

Date of Diagnosis

Repeats (eg: 6/12)

Dispense (Self/Medipost)

Add Remove

Special Investigations

Date

Investigation Description

Result

Add Remove

Additional Information

Complete if relevant to diagnosis.

Weight

Height

BMI

Smoker

Yes

Cigarettes per day

Injuries

Injury on Duty

Previous Motor Accident

Date of Injury on Duty *

Date of Motor Accident *

General Practitioner Signature *

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