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New Zealand Gazette – 2002 – No. 40

Page 1173

✨ Health Claim Form

CLAIM FORM FOR SPECIALIST CONSULTATIONS

[Obstetricians, Anaesthetists, Paediatricians]

MINISTRY OF HEALTH

DETAILS OF AUTHORISED PRACTITIONER

PRACTITIONER ID TYPE
[ ] Medical Council of NZ

REGISTRATION NUMBER
__ (i.e. MCNZ)

AGREEMENT NUMBER □□□□□□□□ - □□

PAYEE NUMBER □□□□□□□□

DETAILS OF WOMAN

NHI □□□□□□□□

D.O.B □□ / □□ / □□ (i.e. month/year)

DETAILS OF BABY

NHI □□□□□□□□

Date of Birth □□ / □□ / □□□□

DETAILS OF REFERRAL

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

REFERRING LMC REGISTRATION NUMBER
____ (i.e. MCNZ, NCNZ)

NAME OF REFERRING LMC

DETAILS OF SPECIALIST CLAIMS

Date of Referral	Date of Service	Principal Reason for Referral (Use Referral Guidelines)	First Consultation (Obstetrician & Paediatrician only)	Subsequent Consultation (Obstetrician & Paediatrician only)	Anaesthetic Services	Specialist Obstetrician - Effecting Birth	Paediatrician Attendance at Delivery	Amount Claimed
□□/□□/□□□□	□□/□□/□□□□	□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□	□	□	□	□	□	$□□□□.□□
□□/□□/□□□□	□□/□□/□□□□	□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□	□	□	□	□	□	$□□□□.□□
□□/□□/□□□□	□□/□□/□□□□	□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□	□	□	□	□	□	$□□□□.□□

TOTAL AMOUNT CLAIMED (GST inclusive) $□□□□□□.□□

CERTIFICATION

I certify that I have provided the above services in accordance with the service specifications to the Section 88 Notice and that the above information is correct. 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

Online Sources for this page:

VUW Te Waharoa — NZ Gazette 2002, No 40

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

The General Assembly Library (on the right) was completed in 1899 and survived the 1907 fire. Now the oldest remaining original Parliament building, still used as the Parliamentary Library.

✨ LLM interpretation of page content

🏥 Claim Form for Specialist Consultations (continued from previous page)

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

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Sources and Attribution

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")
- Issues from 1913-1999
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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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The logo in the header is an edited version of “Winning Coat of Arms Competition Entry, 1908” by Archives New Zealand, CC BY 2.0 (found via Wikipedia).

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.