Specialist Referral Form

IMPORTANT NOTE: This form must be completed by the referring Prime Cure Network Doctor. You can complete this online form, or download a copy of the form and email it to casemanagers@primecure.co.za or call Prime Cure on 0861 665 665. The pre-authorisation number must be recorded on the account for payment. Please submit your account electronically using the following destination code - 642P. Alternatively, you can email your claim to refunds@primecure.co.za. Claims submitted via email may take up to two weeks to process.

Doctor Details

Referring Doctor *

Practice Number *

Email *

Telephone *

Fax

Cell

Details of Principal Member / Policyholder

Surname *

First Name *

Member / Policy Number *

Name of Medical Scheme/Health Insurance *

Medical Scheme/Health Insurance Option

Employer

Paypoint No

Patient Details

Surname *

First Name *

Postal Address *

Postal Address

City

Province

Postal Code

Dependant Code

Telephone

Fax

Cell

Identity Number/Passport *

Gender

Male

Female

Age

Reasons for Referral

Diagnosis *

Motivation for Referral *

ICD-10 Code *

Date of Onset *

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)

Medication Description (eg: HZTZ)

Strength (eg: 25mg)

Directions (eg: 1/Daily)

Date of Diagnosis

Repeats (eg: 6/12)

Dispense (Self/Medipost)

Add Remove

Special Investigations

Date

ICD-10 Code (eg: FBC)

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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