New Zealand Gazette – 2002 – No. 40

Page 1166

✨ Maternity Registration Form



CLAIM FORM FOR

REGISTRATION OF WOMAN WITH LEAD MATERNITY CARER

This form is to be completed when a woman registers with you as her Lead Maternity Carer. It must be completed in full consultation with the woman and a copy provided to her. This form must be submitted to Health Benefits for payment within 22 days of signing.

REGISTRATION TYPE

  • [X] Registration
  • [ ] Change in Lead Maternity Carer

DETAILS OF WOMAN

NHI □□□□□□□ (e.g. ABC1234)
Please phone 0800 855 151 if you need assistance with the NHI.

GRAVIDA □□ PARITY □□ LMP □□/□□/□□□□
(Estimated if necessary)

NAME OF WOMAN
Surname or Family Name __

First Names _____

Previous Surname(s) _____

ADDRESS
Street & Number _____

Suburb __

City/Town ___

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. The woman should select up to three groups with which she identifies.

  • [X] NZ/European
  • [ ] Other European
  • [ ] New Zealand Maori
  • [ ] Samoan
  • [ ] Cook Island Maori
  • [ ] Tongan
  • [X] Niuean
  • [ ] Tokelauan
  • [ ] Fijian
  • [ ] Other Pacific
  • [X] South East Asian
  • [ ] Indian
  • [ ] Chinese
  • [ ] Other Asian
  • [ ] Other

DETAILS OF LEAD MATERNITY CARER

PRACTITIONER ID TYPE

  • [X] Medical Council of NZ
  • [ ] Nursing Council of NZ

REGISTRATION NUMBER ___ (i.e. MCNZ, NCNZ)

NAME OF LEAD MATERNITY CARER __

AGREEMENT NUMBER □□□□□□ - □□

PAYEE NUMBER □□□□□□

DETAILS OF CLAIM

REGISTRATION FEE

AMOUNT PAYABLE (GST inclusive) $ □□□□.□□

CERTIFICATION

WOMAN
I have chosen the above Lead Maternity Carer for my pregnancy care, labour and birth and services following birth. I understand that my Lead Maternity Carer will arrange for any other maternity services that I might need. I understand that I can change my Lead Maternity Carer at any time.

I understand that my Lead Maternity Carer will be forwarding the claim forms to the Ministry of Health and that the Ministry of Health will be using this information to monitor health services in a manner consistent with the Health Information Privacy Code 1994.

Signature of Woman

Date

LEAD MATERNITY CARER
I certify that I have been chosen by the above named woman as her Lead Maternity Carer for pregnancy care, labour and birth and services following birth and that I accept the obligations of a Lead Maternity Carer as detailed in the Section 88 Maternity Notice.

Signature of Lead Maternity Carer

Date



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Online Sources for this page:

VUW Te Waharoa — PDF NZ Gazette 2002, No 40


Gazette.govt.nz — PDF NZ Gazette 2002, No 40




✨ LLM interpretation of page content

🏥 Claim Form for Registration of Woman with Lead Maternity Carer (continued from previous page)

🏥 Health & Social Welfare
Maternity, Claim Form, Registration, Lead Maternity Carer, Health Benefits