✨ Wigs and Hairpieces Claim Form
1412 NEW ZEALAND GAZETTE, No. 55 23 MARCH 2005
Schedule 2
WIGS AND HAIRPIECES 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)
Temporary condition/Permanent condition (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:
3. Medical Certificate (if initial claim)
4. 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 wigs and hairpieces 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.
PUBLISHED BY THE
DEPARTMENT OF INTERNAL AFFAIRS
PRINTED BY WICKLIFFE LIMITED
ISSN 0111-5650
Price $10.00 (inc. G.S.T.)
Online Sources for this page:
VUW Te Waharoa —
NZ Gazette 2005, No 55
Gazette.govt.nz —
NZ Gazette 2005, No 55
✨ LLM interpretation of page content
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Wigs and Hairpieces Claim Summary Form
(continued from previous page)
🏥 Health & Social WelfareWigs, Hairpieces, Claim Form, HealthPAC, Provider Services