OPMED APPLICATION FORM FOR Chronic Disease List Conditions (CDL) and other Chronic Conditions

Transcription

1 OPMED APPLICATION FORM FOR Chronic Disease List Conditions (CDL) and other Chronic Conditions ATTENDING MEDICAL PRACTICIONER TO KINDLY COMPLETE THE RELEVANT SECTIONS AND RETURN ALL PAGES TO: PO Box 8796, Centurion, 0046, fax to or to NB: Please complete one application form per patient. DATE: Patient information Principal Member Number as per Card Dependant code Doctor Information Dr Initials and Surname Dr Practice Number Dr Speciality Address Dr Contact Numbers: (Rooms) (Fax) (Cell) Clinical Entry Criteria for the CDL Conditions to be Completed by the Treating Physician: In order for a patient /beneficiary to qualify for the CDL benefit, the medical practitioner must supply the relevant information per disease condition on the following pages. Authorisations are subject to the Mediscor Basic formulary. The formulary can be viewed at The attending medical practitioner s signature is required on each page to confirm the CDL condition together with the appropriate ICD-10 code. Failure to complete the application, with the relevant signatures from the patient and the treating physician, as well as providing the required information, will result in non-registration of the condition. Declaration: I declare and understand that this application shall be null and void if any information supplied by me and/or my dependants should be false or incomplete. In which case I will repay all monies paid to me and/or my dependants (or on my behalf) by the scheme for benefits received for the treatment of any of the disease conditions ticked. I give my irrevocable consent to any medical doctor, person or organization that may possess, or come into possession of any medical information to disclose this information to the scheme, to the extent permitted by law. SIGNATURE (Principal Member) Signed at on this day of 20 Copyright 2011 Mediscor PBM (Pty) Ltd 2012/03/30 Page 1 of 6

2 PATIENT DETAILS Member Number Patient Dependent Code CARDIOVASCULAR DISEASES Cardiac Failure Cardiomyopathy Coronary Artery Disease Dysrhythmias Hypertension Hyperlipidaemia BP reading: Height: Weight: Exercise: Yes/ No Smoking: Yes / No Date of Lipogram: Lipogram Reading (Please On Off indicate): treatment treatment TCL: LDL: HDL: Triglycerides: Only a diagnosis by an endocrinologist will be accepted to diagnose genetic hyperlipidaemias without supporting high Total Cholesterol values Risk Factors: (Please indicate where applicable) Family History First degree male relative <55yrs First degree female relative <45yrs Peripheral Vascular Disease Hypertension Angina/Myocardial infarction Angioplasty/Stent Cerebrovascular Accident Transient Ischaemic Tendon xantomata (CVA) Attack ENDOCRINOLOGY Addison s Disease Diabetes Insipidus Diabetes Mellitus 1 Diabetes Mellitus 2 Attach results: Water deprivation test Attach results: Casual/random plasma glucose OR Fasting plasma glucose OR OGTT (oral glucose tolerance test); HbA1C Attach results: Casual/random plasma glucose OR Fasting plasma glucose OR OGTT (oral glucose tolerance test); HbA1C; lipogram; BMI For increase in dosage or change to another medicine attach most recent HbA1c results; reason for change in medicine. Hypothyroidism 2

3 RESPIRATORY DISEASES Asthma Bronchiectasis Chronic Obstructive Pulmonary Disease (COPD) Stage 1 Stage 2 Stage 3 Initial FEV 1 (spirometry report): AUTO IMMUNE DISEASES Multiple Sclerosis 1. New application: a. Diagnosis by neurologist or specialist physician with appropriate Practice Number. b. Specify type of MS c. Relapse- remitting history for the past two years d. Reports of all MRI scans of brain e. EDSS (Extended disability status score) f. Report of CSF analysis (if performed) 2. If applying for continued therapy:motivation by a neurologist or specialist physician, including: i. Relapse- remitting history for the past two years ii. EDSS (Extended disability status score) iii. Report of adverse events Systemic Lupus Erythematosus Indication of ACR criteria for rheumatoid arthritis, and how long symptoms have been present: Morning stiffness 1 hour Arthritis of 3 or more of the following joints: Right or left PIP, MCP, wrist, elbow, knee, ankle and MTP joints Arthritis of wrist, MCP or PIP joint Symmetric involvement of joints Rheumatoid Arthritis Rheumatoid nodules over bony prominences, or extensor surfaces, or in juxta-articular regions Positive rheumatoid factor Radiographic changes including erosions or bony decalcification localized in or adjacent to the involved joints. Attach: Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) Rheumatoid factor or Anti-cyclic citrullinated peptide antibodies (anti-ccp) Reports of X-rays performed Disease activity markers: SJC, TJC, Physician s global assessment, Patient s global assessment, CRP or ESR, HAQ and SDAI. 3

4 INFLAMMATORY BOWEL DISEASES Crohn s Disease Attach results: Full blood count (FBC) Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) Appropriate imaging studies sigmoidoscopy or colonoscopy Histology report Ulcerative Colitis Attach results: Full blood count (FBC) Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) Appropriate imaging studies sigmoidoscopy or colonoscopy Histology report CENTRAL NERVOUS SYSTEM DISEASES Bipolar Mood Disorder Psychiatrist or paediatric psychiatrist Practice Number: Epilepsy Parkinson s Disease Schizophrenia Psychiatrist or paediatric psychiatrist Practice Number: OTHER DISEASES Chronic Renal Disease New application: Diagnosis by a specialist physician or nephrologist. Attach: Serum creatinine clearance value or Glomerular Filtration Rate estimate Application for erythropoietin (ESAs): Attach: Iron studies ( ferritin, transferrin saturation); hemoglobin (Hb) level Application for iron supplementation: Attach: Iron studies ( ferritin, transferrin saturation); hemoglobin (Hb) level Application for phosphate binders: Attach: Calcium, phosphate, PTH Glaucoma Haemophilia Prescribing Doctor Signature: Attach results: Factor VIII or Factor IX levels Date: Patient Signature: 4

5 HIV / AIDS 1. Diagnosis by a registered practitioner. 2. Following laboratory results must be attached a. CD4 count b. Viral load (VL) c. Electrolytes d. Liver function e. Renal function ONCOLOGY Pre-authorisations for oncology is managed by Medical Services Organisation (MSO) contact number OTHER CHRONIC CONDITIONS: Please note: The following conditions may be reimbursed from the chronic benefit subject to clinical protocol and criteria. * Additional information may be required Disease ICD-10 Code Clinical Remarks Alzheimer s disease* Attach: Diagnosis by neurologist or psychiatrist. Auto-Immune disease (e.g. Scleroderma) Allergic Rhinitis (in presence of asthma) Chronic depression* Cushing s disease Cystic Fibrosis Endometriosis Gastro oesophageal reflux disease Attach: Gastroscopy report Gout Hyperthyroidism Hypoparathyroidism Menopause (Hormone replacement therapy) Motor neurone disease Myastenia Gravis Obsessive compulsive disorder Osteo-arthritis Osteoporosis* Attach: 1. DEXA bone mineral density scan (BMD) Report 2.Information on additional risk factors in patient such as smoking, alcohol use, previous osteoporotic fracture, corticosteroid use 5

6 Pituitary Micro-adenoma Prostatic hypertrophy(benign) Psoriasis Stroke (cerebrovascular accident) Date of incident: Medicine prescribed DESCRIPTION DOSAGE STRENGTH Prescribing Doctor Signature: Date: 6