✨ Maternity Claim Application Form
NEW ZEALAND GAZETTE
No. 40
APPENDIX VII
APPLICATION FORM & CLAIM FORMS
APPLICATION FORM FOR
AUTHORISATION TO CLAIM UNDER THE MATERNITY NOTICE
DETAILS OF AUTHORISED PRACTITIONER
PRACTITIONER ID TYPE
[ ] Medical Council of NZ
[X] Nursing Council of NZ
REGISTRATION NUMBER
__ (i.e. MCNZ, NCNZ)
OCCUPATION
[X] Midwife
[ ] General Practitioner
[ ] General Practitioner (Dip. Obs.)
[ ] Anaesthetist
[ ] Obstetrician
[ ] Radiologist
[ ] Paediatrician
COPY OF PRACTISING CERTIFICATE ATTACHED
[X]
NAME
Surname or Family Name: _
First Name: ___
Middle Name(s): _____
ADDRESS
Principal Practice Address | Postal Address
Building name: _ | __
Street Number: _ | __
Suburb: | __
City: __ | __
CONTACT DETAILS
Phone:
Fax Number: ____
Mobile: ____
Pager:
Email: _____
SEX
[X] Female
[ ] Male
Date of Birth: [ ][ ][ / ][ ][ ][ ][ ][ ]
ETHNICITY
Completion of this section will assist the monitoring of health trends amongst different ethnic groups. The categories comply with NZHIS standards. Select up to three groups that you identify with.
[X] NZ/European
[ ] Other European
[X] New Zealand Maori
[ ] Samoan
[X] Cook Island Maori
[ ] Tongan
[ ] Niuean
[ ] Tokelauan
[ ] Fijian
[ ] Other Pacific
[ ] Indian
[ ] South East Asian
[ ] Chinese
[ ] Other Asian
[ ] Other
DETAILS OF PAYEE
DIRECT CREDIT DETAILS (Please note that Countrywide Bank Accounts will have an extra digit)
Bank Account Number: [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
GST REGISTERED
[ ] Yes
[X] No
My GST number is: [ ][ ][ ][ ][ ][ ][ ][ ][ ]
CLAIMS WILL BE MADE
[ ] Manually
[X] Electronically
DETAILS OF ORGANISATION HOLDING AUTHORISATION
NAME OF ORGANISATION (where organisation holds the authorisation)
POSTAL ADDRESS (where different from above)
Next Page →
Online Sources for this page:
VUW Te Waharoa —
NZ Gazette 2002, No 40
Gazette.govt.nz —
NZ Gazette 2002, No 40
✨ LLM interpretation of page content
🏥 Application Form for Maternity Claim Authorisation
🏥 Health & Social WelfareMaternity, Claim Form, Authorisation, Practitioner Details, Midwife