New Zealand Gazette – 2005 – No. 55

Page 1379

✨ Health Services Claim Form



23 MARCH 2005

NEW ZEALAND GAZETTE, No. 55

1379

MINISTRY OF HEALTH

Schedule 2

BREAST PROSTHESES CLAIM FORM

To be completed by the Eligible Person

Please print clearly and legibly

Full Name:

Residential Address:

Date of Birth:

CLAIM DETAILS

Initial claim/Subsequent claim (Please delete as appropriate)

Left/Right/Bilateral (Please delete as appropriate)

Date of Purchase:

Item(s) Purchased:

Total $ Amount of Purchase:

Total $ Amount Claimed:

Note: The following documents must accompany this form:

  1. Medical Certificate (if initial claim)
  2. Proof of Purchase

CERTIFICATION

(Please tick the appropriate box)

[ ] I am submitting this claim on my own behalf. My HealthPAC payee number is:

[ ] I am authorising my Provider to claim for this service on my behalf.

I declare that as an Eligible Person, I am entitled to publicly funded health care in accordance with any eligibility direction issued under Section 32 of the New Zealand Public Health and Disability Act 2000, or any eligibility direction continued by Section 112 (1) of that Act and declare that I am not eligible for any kind of assistance from the Accident Compensation Corporation. I certify that as the Eligible Person named above I have been supplied with the breast prostheses services claimed.

Signature:

Date:

HEALTHPAC USE ONLY

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 — PDF NZ Gazette 2005, No 55


Gazette.govt.nz — PDF NZ Gazette 2005, No 55




✨ LLM interpretation of page content

🏥 Breast Prostheses Claim Form (continued from previous page)

🏥 Health & Social Welfare
Claim Form, Breast Prostheses, Eligibility, Payment, Health Services