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New Zealand Gazette – 2002 – No. 40

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✨ Health Claim Form

1172

NEW ZEALAND GAZETTE

No. 40

CLAIM FORM FOR ULTRASOUND CONSULTATION

MINISTRY OF HEALTH
MANATŪ HAUORA

DETAILS OF AUTHORISED PRACTITIONER

PAYEE NUMBER [ ] [ ] [ ] [ ] [ ] [ ]

AGREEMENT NUMBER [ ] [ ] [ ] [ ] [ ] - [ ] [ ]

DETAILS OF WOMAN/BABY

NHI [ ] [ ] [ ] [ ] [ ] [ ] [ ] EDD [ ] [ ] / [ ] [ ] i.e. month/year (Not applicable for baby)

LMP [ ] [ ] / [ ] [ ] / [ ] [ ] [ ] [ ] Estimated if necessary (Not applicable for baby)

SCAN FOR [X] Mother [X] Baby (not foetus)

DETAILS OF REFERRAL

REFERRING PRACTITIONER ID TYPE [X] Medical Council of NZ [X] Nursing Council of NZ

REFERRING PRACTITIONER REGISTRATION NUMBER [____] (i.e. MCNZ, NCNZ)

PRINCIPAL REASON FOR REFERRAL [ ] [ ] [ ] (use Ultrasound Indications List – e.g. MF3)

DATE OF REFERRAL [ ] [ ] / [ ] [ ] / [ ] [ ] [ ] [ ]

SECOND / THIRD TRIMESTER ONLY

NAME OF LEAD MATERNITY CARER [__]

NON-LMC REFERRAL AND EMERGENCY CIRCUMSTANCES [X] Yes [X] No

DETAILS OF SERVICE AND CLAIM

DATE OF SCAN [ ] [ ] / [ ] [ ] / [ ] [ ] [ ] [ ]

TOTAL AMOUNT CLAIMED (GST inclusive) $ [ ] [ ] [ ] : [ ] [ ]

CERTIFICATION

I certify that I have provided the above services in accordance with the service specifications in the Section 88 Notice and that the above information is correct. The scan has been performed as a result of a referral from the Authorised Practitioner identified in the details of the referral above. I understand that the information will also be used to monitor the quality of patient care, treatment and health statistics in a manner consistent with the Health Information Privacy Code 1994.

[____]
Name of Authorised Practitioner (Capital letters please)

[__] [____]
Signature of Authorised Practitioner Date

VUW Te Waharoa — NZ Gazette 2002, No 40

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

The Executive Wing of Parliament (depicted) is universally known as The Beehive. It was completed in 1977 and remains the primary office for the elected Government of the day.

✨ LLM interpretation of page content

🏥 Claim Form for Ultrasound Consultation (continued from previous page)

Domain🏥 Health & Social Welfare
KeywordsUltrasound, Claim Form, Maternity, Health Benefits, Referral

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NZ Gazette Sources

The primary sources for the issues of the NZ Gazette indexed by this project are:

New Zealand Gazette Archive, provided by Victoria University Library, copyright 2008 LexisNexis NZ Limited, Crown Copyright of New Zealand Gazette Office
- Issues from 1841-2008, including the New Munster, New Ulster, and Provincial Gazettes
New Zealand Gazettes by New Zealand Legal Information Institute (note: "NZLII is not the copyright owner in the source documents published on NZLII")
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Additional Sources

Wellington City Recollect have made available a comprehensive and excellent-quality scan of the Wellington Provincial Gazette which was used to fill in a number of issues missing from Victoria University's Gazette Archive; in particular, all 1856 issues, issues 22-34 for 1864 and issues 9-19 for 1870.
27 issues of The New Zealand Advertiser and Bay of Islands Gazette (1840) were sourced from Papers Past (public domain).
Gazette Extraordinary No. 1 (1840), held at the Alexander Turnbull Library, Wellington, New Zealand. Imaged by Luke Howison at the National Library reading rooms; PDF released into the public domain.

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Who made this?

I'm Luke Howison, a freelance web developer with an interest in genealogy. I have created several websites for genealogical research, such as NZ Ancestor Search Helper.

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