✨ Maternity Claim Form
24 APRIL NEW ZEALAND GAZETTE 1169
CLAIM FORM FOR SERVICES FOLLOWING BIRTH
DETAILS OF LEAD MATERNITY CARER AND WOMAN
NHI □□□□□□ EDD □□/□□ e.g. mm/dd/yy
PRACTITIONER ID TYPE □ Medical Council of NZ □ Nursing Council of NZ
REGISTRATION NUMBER __ (i.e. MCNZ, NCNZ)
AGREEMENT NUMBER □□□□□□-□□ PAYEE NUMBER □□□□□□
DETAILS OF BABY(S)
BREASTFEEDING
Baby 1 Infant feeding at 2 weeks Exclusive □ Fully □ Partial □ Artificial □
Baby 2 (where applicable) Infant feeding at 2 weeks Exclusive □ Fully □ Partial □ Artificial □
Baby 1 At discharge from LMC Exclusive □ Fully □ Partial □ Artificial □
Baby 2 (where applicable) At discharge from LMC Exclusive □ Fully □ Partial □ Artificial □
DATE OF BIRTH
Baby 1 □□/□□/□□□□
Baby 2 □□/□□/□□□□ (where applicable)
DATE OF DISCHARGE FROM MATERNITY CARE
Baby 1 □□/□□/□□□□
Baby 2 □□/□□/□□□□ (where applicable)
DATE OF NEONATAL DEATH (where applicable)
Baby 1 □□/□□/□□□□
Baby 2 □□/□□/□□□□ (where applicable)
BABY(S) 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.
□ NZ European □ Samoan □ Other Pacific □ Indian
□ Other European □ Cook Island Maori □ Tokelauan □ South East Asian □ Other Asian
□ New Zealand Maori □ Tongan □ Fijian □ Chinese □ Other
DETAILS OF SERVICE
NUMBER OF MIDWIFERY HOME VISITS RECEIVED BY WOMAN/BABY □□ (Annotate number of Visits)
NUMBER OF VISITS DURING INPATIENT POSTNATAL STAY BY LMC OR BACK-UP TO LMC □□ (Annotate number of Visits)
REFERRAL TO WELL CHILD PROVIDER Yes □ No □ (WOMAN DECLINED REFERRAL TO WELL CHILD PROVIDER)
GP NOTIFIED Yes □ No □ (WOMAN DECLINED NOTIFICATION TO GP)
DETAILS OF REFERRALS
| Date of Referral | Name of Practitioner or Secondary Care Service referred to | Specialist Type (e.g. Paediatrician) | Reason for Referral (Use Referral Guidelines) |
|---|---|---|---|
| Mother | □□□□ | ||
| □□/□□/□□ | □□□□ | ||
| □□/□□/□□ | □□□□ | ||
| Baby | □□□□ | ||
| □□/□□/□□ | □□□□ | ||
| □□/□□/□□ | □□□□ |
WOMAN TRANSFERRED TO SECONDARY MATERNITY Yes □ No □ If yes, date of transfer □□/□□/□□ □□□□
DETAILS OF CLAIM
WOMAN RECEIVES INPATIENT CARE
Lead Maternity Care Circle applicable one $□□□□.□□
Full Module / First Partial / Last Partial
GP/Obstetrician Lead Maternity Care (where Hospital Midwifery Services used) Full Module / First Partial / Last Partial $□□□□.□□
Hospital Midwifery Services Full Module / First Partial / Last Partial $□□□□.□□
WOMAN RECEIVES NO INPATIENT CARE
Lead Maternity Care Full Module / First Partial / Last Partial $□□□□.□□
GP/Obstetrician Lead Maternity Care (where Hospital Midwifery Services used) Full Module / First Partial / Last Partial $□□□□.□□
Hospital Midwifery Services Full Module / First Partial / Last Partial $□□□□.□□
ADDITIONAL HOME VISITS
$□□□□.□□
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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 Services Following Birth
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🏥 Health & Social WelfareMaternity, Claim Form, Services Following Birth, Health Benefits