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 firstname.lastname@example.org 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 email@example.com. Claims submitted via email may take up to two weeks to process.
Concomittant Medication - Patient Current Medication