✨ Breast Prostheses Claim Form
NEW ZEALAND GAZETTE, No. 55
23 MARCH 2005
1378
Schedule 1
BREAST PROSTHESES CLAIM SUMMARY FORM
To be completed by the Provider of services
Please print clearly and legibly.
HealthPAC Payee Number:
Section 88 Notice Number:
Full Name:
Business Address:
CLAIM DETAILS
Total Number of Initial Claims:
Total Number of Subsequent Claims:
Total Number of Claims Attached:
Total $ Amount Claimed:
All claim forms to which this Claim Summary Form relates must be attached to this form.
CERTIFICATION
I certify that the Eligible Persons whose names are attached have been supplied with the breast prostheses services claimed. I claim the above amount on behalf of these Eligible Persons.
Signature of Provider:
Date:
HEALTHPAC USE ONLY
Total Number of Initial Claims Payable:
Total Number of Subsequent Claims Payable:
Total $ Amount Payable:
Checked By:
Date:
All claims for payment are to be sent to: HealthPAC, PO Box 1026, Wellington.
For further enquiries, telephone toll free on 0800 458 448.
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Online Sources for this page:
VUW Te Waharoa —
NZ Gazette 2005, No 55
Gazette.govt.nz —
NZ Gazette 2005, No 55
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