✨ Maternity Claim Form
CLAIM FORM FOR SECOND TRIMESTER, THIRD TRIMESTER AND LABOUR AND BIRTH
DETAILS OF LEAD MATERNITY CARER
| PRACTITIONER ID TYPE | ☑ Medical Council of NZ | ☐ Nursing Council of NZ |
|---|---|---|
| REGISTRATION NUMBER | ____ | (i.e. MCNZ, NCNZ) |
| AGREEMENT NUMBER | □□□□□□□□ | PAYEE NUMBER |
DETAILS OF WOMAN
| NHI | □□□□□□□□ | □□ | □□ | L.e. month/year |
| LMP | □□ / □□ / □□□□ |
| MATERNAL DEATH (where applicable) | ☐ |
| (Estimated if necessary) |
DETAILS OF SERVICE
| DATE OF BIRTH | Baby 1 | □□ / □□ / □□□□ | Baby 2 (where applicable) | □□ / □□ / □□□□ |
| APGAR SCORE | ☐ At 5 Minutes | □ | ☐ At 5 Minutes | □ |
| CONDITION | ☑ Liveborn ☐ Stillborn | ☐ Liveborn ☐ Stillborn |
| BIRTH WEIGHT | □□□□ gm | □□□□ gm |
| NHI OF LIVEBORN BABY | □□□□□□□□ | □□□□□□□□ |
| PLACENTA KEPT BY WOMAN | ☐ Yes ☐ No |
| LMC ATTENDANCE AT BIRTH | ☐ Yes ☐ No |
| NUMBER OF VISITS RECEIVED IN SECOND TRIMESTER AND THIRD TRIMESTER MONTHS | □□ (Annotate number of visits) |
| WOMAN HAS HAD THE FOLLOWING TESTS DURING THIS PREGNANCY |
| CHORIONIC VILLOUS SAMPLING | ☐ Yes ☐ No |
| FOETAL BLOOD SAMPLING | ☐ Yes ☐ No |
| AMNIOCENTESIS | ☐ Yes ☐ No |
DETAILS OF REFERRALS
| Date of Referral | Name of Practitioner or Secondary Maternity Service referred to | Specialist Type (e.g. Radiologist) | Reason for Referral (use Referral Guidelines) |
|---|---|---|---|
| □□□□□□ | |||
| □□□□□□ | |||
| □□□□□□ | |||
| □□□□□□ |
| WOMAN TRANSFERRED TO SECONDARY MATERNITY | ☐ Yes ☐ No | If yes, Second ☐ Third ☐ Labour & Birth ☐ |
| Transfer Date | □□ / □□ / □□□□ |
DETAILS OF CLAIM
| SECOND TRIMESTER |
| Date module ended | □□ / □□ / □□□□ | Circle applicable one: Full Module / First Partial / Last Partial | $ □□□□□□ |
| THIRD TRIMESTER |
| Date module ended | □□ / □□ / □□□□ | Circle applicable one: Full Module / First Partial / Last Partial | $ □□□□□□ |
| LABOUR AND BIRTH |
| Lead Maternity Care | First Birth / VBAC / Subsequent Birth | $ □□□□□□□ |
| GP/Obstetrician Lead Maternity Care (where Hospital Midwifery Services used) | First Birth / VBAC / Subsequent Birth | $ □□□□□□□ |
| Hospital Midwifery Services | First Birth / VBAC / Subsequent Birth | $ □□□□□□□ |
| Homebirth Supplies & Services | $ □□□□□□ |
| Birth occurred at home | ☐ Yes ☐ No |
| Birthing Unit Services | $ □□□□□□ |
| Name of Birthing Unit | ____ |
LESS DISBURSEMENTS TO AUTHORISED PRACTITIONERS
| Payee Number of Recipient | Payee Name | Amount to pay |
|---|---|---|
| □□□□□□□□□□□□ | ____ | $ □□□□□□□□ |
| □□□□□□□□□□□□ | ____ | $ □□□□□□□□ |
| TOTAL AMOUNT CLAIMED | (GST inclusive) | $ □□□□□□□ |
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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
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Claim Form for Second Trimester, Third Trimester, and Labour and Birth
(continued from previous page)
🏥 Health & Social WelfareMaternity, Claim Form, Second Trimester, Third Trimester, Labour and Birth, Health Benefits