1. Healthcare

CHRONIC MEDICATION BENEFIT APPLICATION FORM
Please complete this applica on form as follows:
The member of the plan must fill in all personal and membership details in Sec on 1 & 2.
Please make sure you complete both these sec ons in full, in order to effec vely process your applica on.
The doctor must fill in all medical informa on required in Sec on 3 & 4 of the applica on form.
Please fax or Email your applica on to the following:
Fax Number: 086 607 9419
Email: chronic@affinityhealth.co.za
SECTION 1: PRINCIPAL MEMBER INFORMATION
Surname:
Ini als:
Title:
Date of Birth:
Prof
d
Dr
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m
Mr
m
Mrs
y
y
y
Miss
Ms
Mst
Iden ty Number:
Membership Number:
y
Medical Aid Plan:
Op on 1:
Employer:
Email Address
Tel No Home
Tel No Work
Cell
SECTION 2: IMPORTANT PATIENT INFORMATION
Surname:
Title
Prof
Dr
Mr
Mrs
Miss
Ms
First Names
Date of Birth:
d
d
m
m
y
y
y
Iden ty Number
y
Tel No Home
Tel No Work
Cell
Rela onship to Member
Mass Kg
Gender
Height (cm)
How long have you smoked for?
D
Do you smoke?
D
M
M
Y
Y
Y
N
Dependent Code
If yes how many cigare es a day?
Do you consume alcohol?
If yes, state type and
quan ty
If you have any chronic medica on queries please call the Chronic Helpdesk / Customer Services: Tel. 0861 11 00 33
Mst
Funding from the Chronic Medica on Benefit is subject to clinical entry criteria, the medica on acquisi on rules and formulary determined by Affinity
Health (Pty) Ltd and agreed to by the scheme.
Please Note: AFFINITY HEALTH (PTY) LTD adopts a medica on reimbursement policy adhering to the single exit pricing structure for all generic and
brand name medica on. This policy will be implemented at all points of service across all benefit plans and no excep on sha ll be made except where
prior authorisa on has been obtained from AFFINITY HEALTH (PTY) LTD.
Should a “non-preferred” medica on be required to treat an approved chronic condi on, your GP is required to give mo va on for this medica on
via our Medica on Appeals Procedure. Medica on not pre-authorised as chronic by AFFINITY HEALTH (PTY) LTD may be eligible for reimbursement
from the Chronic Medica on Benefit.
I hereby give permission for the GP to state my diagnoses and other relevant clinical informa on on this form.
By applying for the Chronic Medica on Benefit, I agree that my condi on may be subject to disease management interven ons.
Signed Principal
Member Pa ent (Unless a Minor)
Date
SECTION 3: RULES APPLICABLE TO CHRONIC MEDICATION BENEFIT (CMB)
1. All personal and medical details must be submi ed accurately by the GP and the pa ent where specifically requested.
Certain chronic condi ons require addi onal clinical informa on to be submi ed with this applica on form. Following Drug U lisa on Review,
addi onal clinical informa on may also be requested .
2. Certain chronic conditions require addi onal clinical informa on to be submi ed with this application form. Following Drug Utilisa on
Review, additional clinical informa on may also be requested.
Cardiovascular Diseases:
Chronic Diagnosis
√
ICD-10 Code
Clinical / Laboratory Supporting Documentation
Cardiac Failure
Cardiomyopathy
Coronary Artery Disease
Dysrhythmias
Hypertension
BP Reading
Hyperlipidaemia
Addi onal Informa on - Hyperlipidaemia
Exercise
Y
N
BP Reading
Smoking
Y
N
If yes, how many cigarettes a day?
Lipogram Reading (Ini al/Diagnostic)
TCL:
Date of Lipogram:
LDL:
HDL:
d
d
m
m
y
y
y
y
Triglycerides:
Risk Factors: (Please indicate where applicable)
Angina/Myocardial infarction
Angioplasty/Stent
Cerebrovascular Accident (CVA)
Family History
Peripheral Vascular Disease
Transient Ischaemic A ack
Endocrine Diseases:
Chronic Diagnosis
√
ICD-10 Code
Clinical / Laboratory Supporting Documentation
Addison’s Disease
Diabetes Insipidus
Diabetes Mellitus 1
Diabetes Mellitus 2
Hypothyroidism
Addi onal Informa on – Diabetes
Mellitus 1 or 2
Fasting glucose:
Glucose tolerance test:
Date:
d
d
m
m
y
y
y
y
Date:
d
d
m
m
y
y
y
y
Respiratory Diseases:
Chronic Diagnosis
√
ICD-10 Code
Clinical / Laboratory Supporting Documentation
Asthma
Bronchiectasis
Stage 1
Chronic Obstruc ve Pulmonary
Disease (COPD)
Stage 2
Stage 3
Ini al FEV 1 (spirometry report):
Auto Immune Diseases:
Chronic Diagnosis
Mul ple Sclerosis*
√
ICD-10 Code
Clinical / Laboratory Supporting Documentation
* Please note that confirma on of diagnosis by MRI scan is required
from a Neurologist
Neurologist Prac ce Number:
Systemic Lupus
Erythematosus
Rheumatoid Arthritis*
* Please note that confirma on of diagnosis is required from a
Rheumatologist
Rheumatologist Prac ce Number:
Gastrointes nal Diseases:
Chronic Diagnosis
√
ICD-10 Code
Clinical / Laboratory Supporting Documentation
√
ICD-10 Code
Clinical / Laboratory Supporting Documentation
√
ICD-10 Code
Clinical / Laboratory Supporting Documentation
√
ICD-10 Code
Clinical / Laboratory Supporting Documentation
Crohn’s Disease*
Ulcera ve Colitis
Neurologic Diseases:
Chronic Diagnosis
Epilepsy
Parkinson’s Disease
Ophthalmological Diseases:
Chronic Diagnosis
Glaucoma
Other Diseases:
Chronic Diagnosis
Chronic Renal Disease*
Glomerular Filtration rate/Crea nine clearance
HIV
CD4 count
1. All AFFINITY HEALTH (PTY) LTD rules and exclusions will be applied during the review and authorisa on of requested chronic medica on in
respect of any chronic illness.
2. Only approved General Prac oners within AFFINITY HEALTH (PTY) LTD’s Provider Network may apply for chronic medica on benefits on behalf
of AFFINITY HEALTH (PTY) LTD members on the contracted Benefit Plans.
3. All approved chronic medica on may only be obtained from a dispensary within the Medication Distribution Network authorised by AFFINITY
HEALTH (PTY) LTD.
4. General Exclusions from Chronic Medication Benefit (C.M.B) include these commonly requested medicines: Exclusions as detailed in the General
Prac tioner Provider Manual
5. Access to any medication through the C.M.B is subject to Clinical Entry Criteria and Drug Utilisation Review.
6. Disease marked with * will exclude biological medication.
SECTION 4: CURRENT MEDICATION REQUIRED
Diagnosis
Medica on Name, Strength
and Dosage
Dura on on Medication
Monthly Quan ty
Repeats
Years
Months
Are any of the above Diagnoses related to injury on duty?
Y
N
If yes, please state:
Date of Injury
Injury on Duty (IOD) Number:
d
d
m
m
y
y
y
y
MEDICATION HISTORY IF DIFFERENT FROM CURRENT
Year
Diagnosis
Medica on and Strength
Dura on of use
Pa ent Allergies:
State any other illnesses the pa ent suffers from:
May current medica on be subs tuted with a generic if appropriate?
Y
N
SECTION 5: DOCTOR’S DETAILS
Surname:
Prac ce Postal Address:
Code:
Prac ce Physical Address:
Code:
Tel No:
Fax No:
Specialty
E mail
Address:
BHF Prac ce Number
HPC SA REG No
Doctor’ Signature
Date
d
Postnet Suite 124 Private Bag X101 Farrarmere Benoni 1518 Fax Number: 086 607 9419
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m
m
y
y
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y