✨ Health Claim Form
DETAILS OF AUTHORISED PRACTITIONER AND CLAIM
MINISTRY OF HEALTH | MANAWATŪ-WHANGANUI
PRACTITIONER IN TYPE
Medical Council of NZ | Nursing Council of NZ
Registration No. (e.g. MCNZ, NCNZ): __
Appointment Number | PAYEE NUMBER | PAYEE NAME
CERTIFICATION
I certify I have provided the above services in accordance with the above Section 88 Notice specifications and that the above information is correct.
Named Authorised Practitioner (Capital Letters): __
Signature of Authorised Practitioner: __
Date: //___
TOTAL AMOUNT CLAIMED
(GST inclusive) $ _.
DETAILS OF SERVICES AND CLAIM
| Date of Service | LMP | EDD (i.e. month/year) | NHI | 1st Trimester | 2nd Trimester | 3rd Trimester | Unregistered Woman | Pregnancy Care (Code required) | Urgent Out of Hours Pregnancy Care (Code required) | Assessment Prior to TOP | Exceptions (Code required) | Miscarriage Services | Threatened Miscarriage | Postnatal Care from LMC (End date of birth of baby) | Postnatal Circumstances (Code required) | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | //___ | //___ | //___ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | |
| 2 | //___ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | |||||
| 3 | //___ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | |||||
| 4 | //___ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | |||||
| 5 | //___ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ |
CODING FOR EXCEPTIONAL CIRCUMSTANCES
- Unregistered Woman
- Transfer to Secondary Maternity 48 hours prior to Established Labour
- Urgent Non-LMC assistance to Rural LMC
- Ambulance Transfer
DETAILS OF REFERRALS
| Date of Referral | Name of Practitioner or Secondary Maternity Service | Speciality Type (e.g., Obstetrician) | Reason for Referral (Use Referral Guidelines) | |
|---|---|---|---|---|
| 1 | //___ | |||
| 2 | //___ | |||
| 3 | //___ | |||
| 4 | //___ |
AMOUNT CLAIMED
| Amount Claimed | 01/02/03 | 01/03/03 | 01/04/03 | 5/03/03 | 06/03/03 | 07/03/03 | 07/04/03 | 08/04/03 | 08/05/03 | 15/05/03 | 31/05/03 | 01/06/03 | 05/06/03 | 01/07/03 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ | □ |
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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
(continued from previous page)
🏥 Health & Social WelfareMaternity, Claim Form, Services Following Birth, Health Benefits