DAY1 HEALTH CHRONIC MEDICATION BENEFIT APPLICATION FORM

Transcription

1 DAY1 HEALTH CHRONIC MEDICATION BENEFIT APPLICATION FORM Please complete this applica on form as follows: The member of the plan must fill in all personal and membership details in Sec on 1 & 2. Please make sure you complete both thee sec ons in full, in order to effec vely process your applica on. The doctor must fill in all medical informa on required in Sec on 3 & 4 of the applica on form. PLEASE FAX OR YOUR APPLICATION TO: Fax: chronic@1doctor.co.za SECTION 1: PRINCIPAL MEMBER INFORMATION. Surname Ini als Title Prof Dr Mr Mrs Miss Ms Mast Iden ty Number Date of Birth Membership Number Medical Aid Plan Op on 1 Employer Where would you like your medicine delivered? Code Address Tel No Home Work Cell SECTION 2: IMPORTANT PATIENT INFORMATION. Surname (if different) Title Prof Dr Mr Mrs Miss Ms Mast First Names

2 Date of Birth Tel No Home Cell Iden ty Number Work Rela onship to Member Gender M F Dependant Code Mass (kg) Height (cm) Do you smoke? Y N If yes, how many cigare es a day? How long have you smoked for? Do you consume alcohol? Y N If Yes, state type, quan ty and frequency If you have any chronic medica on queries, please contact the 1Doctor Chronic Helpdesk at Funding from the Chronic Medication Benefit is subject to clinical entry criteria, the medication acquisition rules and formulary determined by One Doctor health (Pty) Ltd and agreed to by the scheme. Please Note: ONE DOCTOR HEALTH (PTY) LTD adopts a medication reimbursement policy adhering to the single exit pricing structure for all generic and brand name medication. This policy will be implimented at all points of service across all benefit plans and no exception shall be made except where prior authorisation has been obtained from ONE DOCTOR HEALTH (PTY) LTD. Should non-preferred medication be required to treat an approved chronic condition, your GP is required to give motivation for this medication via our Medication Appeals Procedure. Medication not pre-authorised as chronic by ONE DOCTOR HEALTH (PTY) LTD may be eligible for reimbursement from the Chronic Medication Benefit. I hereby give permission for the GP to state my diagnoses and other relevant clinical informa on on this form. By applying for the Chronic Medica on Benefit, I agree tat my condi on my be subject to disease management interven ons. Signed Principal Member Pa ent (unless a Minor) Date

3 SECTION 3: RULES APPLICABLE TO CHRONIC MEDICATION BENEFIT (CMB) 1. All personal and medical details must be submi ed accurately by the GP and the pa ent where specifically requested. 2. Certain chronic condi ons require adi onal clinical informa on to be submi ed with this applica on form. Following Drug U lisa on Review, addi onal clinical informa on may also be requested. Cardiovascular Diseases: Cardiac Failure Cardiomyopathy Coronary Artery Disease Dysrhythmias Hypertension Hyperlipidaemia Addi onal Informa on - Hyperlipidaemia Exercise Smoking Lipogram Reading (Ini al/diagnos c) TCL: Risk Factors: (Please indicate where applicable) Y Y N N BP Reading BP Reading If yes, how may cigarettes a day? Date of Lipogram: LDL: HDL: Triglycerides: Angina/Myocardial Infarc on Angioplasty/Stent Cerebrovascular Accident (CVA) Family History Peripheral Vascular Disease Transient Ischaemic A ack Endocrine System: Addison s Disease Diabetes Insipidus Diabetes Mellitus 1 Diabetes Mellitus 2 Hypothyroidism Addi onal Informa on - Diabetes Mellitus 1 or 2 Fas ng Glucose: Glucose tolerance test: Respiratory Diseases: Date: Date: d d m m y Asthma Bronchiectasis Chronic Obstruc ve Pulmonary Disease (COPD) Stage 1 Stage 2 Stage 3 Ini al FEV 1 (spirometry report):

4 Auto Immune Diseases: Mul ple Sclerosis* *Please Note that confirma on of diagnosis by MRI scan is required from a Neurologist. Neurologist Practice Number: Systemic Lupus Erythematosus Rheumatoid Arthri s* *Please Note that confirma on of diagnosis by MRI scan is required from a Neurologist. Neurologist Practice Number: Gastrointes nal Diseases: Chron s Disease* Ulcera ve Coli s Neurological Diseases: Epilepsy Parkinson s Disease Ophthalmological Diseases: Glaucoma Other Diseases: Chronic Renal Disease* HIV Glomerular Filtra on rate/crea nine clearance CD4 count 3. All ONE DOCTOR HEALTH (PTY) LTD rules and exclusions will be applied during te review and authorisa on of requested chronic medica on in respect of any chronic illness. 4. Only approved General Prac oners within ONE DOCTOR HEALTH (PTY) LTD s Provider Network may apply for chronic medica on benefits on behalf of ONE DOCTOR HEALTH (PTY) LTD members on the contracted benefit plans. 5. All approved chronic medica on may only be obtained from a dispensary within the Medica on Distribu on Network authorised by All ONE DOCTOR HEALTH (PTY) LTD. 6. General Exclusions from Chronic Medica on Benefit (C.M.B) include these commonly requested medicines: Exclusions as detailed in the General Pac oner Provider Manual. 7. Access to any medica on through the C.M.B is subject to Clinical Entry Criteria and Drug U lisa on Review. 8. Diseases marked with * will exclude biological medica on. SECTION 4: CURRENT MEDICATION REQUIRED Diagnosis Medica on Name, Strength and Dosage Monthly Quan ty Dura on on Medica on Years Months Repeats

5 Are any of the above Diagnoses related to injury on duty? Y N If yes, please state: Date of injury Injury on Duty (IOD) Number: MEDICATION HISTORY IF DIFFERENT FROM CURRENT Year Diagnosis Medica on and Strength Dura on of use Pa ent Allergies: State any other illnesses the pa ent suffers from: May current medica on be subs tuted with a generic if appropriate? Y N SECTION 5: DOCTOR S DETAILS Name Prac ce Postal Address Prac ce Physical Address? Code Code

6 Tel No Speciality BHF Prac ce No Doctor s Signature Fax No Address HPC SA REG No Date