Chronic Benefit Application Form Cardiovascular Disease and Diabetes
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1 Chronic Benefit Application Form Cardiovascular Disease and Diabetes 19 West Street, Houghton, South Africa, 2198 Postnet Suite 411, Private Bag X1, Melrose Arch, 2076 Tel: +27 (11) Fax: +27 (11) Instructions 1. Complete this application form to register for chronic benefits for the first time or to register an additional chronic condition. 2. Please write in legible capitals and indicate your choice by making a tick ( ) in the appropriate spaces. 3. Complete one application form for each patient requiring chronic benefits. 4. The principal member or patient must complete Sections 1 and 2 in full. 5. The treating doctor must complete Sections 3 to 6 where applicable. 6. If the appropriate sections are not completed, we will not be able to process your application. 7. Attach copies of any reports to support diagnosis of chronic condition, where applicable. 8. Please fax completed forms and results to or to mafricahrm@momentumafrica.com Section 1 - Principal Member Information Member Surname: Initials: Medical Scheme: Membership Number: Option: Section 2 - Patient Information Patient Surname: Initials: Title: First Name(s): Gender: Male Female Date of Birth: Dependant Code: Next of Kin: Postal Address: Postal Code: Contact Numbers: Home Work Cell Phone Fax No: Address Please indicate the method whereby you would prefer to receive your letter of authorisation: Fax Post Provider I hereby give permission for my doctor to provide Momentum Africa with my diagnosis and other relevant clinical information required. I understand that funding from the Chronic benefit is subject to clinical entry criteria and drug utilisation review as determined by the Momentum Africa Disease Management Programme. By registering for the Momentum Africa Disease Management Programme, I am aware that my condition may be subject to periodic review and that this may include access to my medical records and disclosure of general and medical information supplied to Momentum Africa. Generic medication or therapeutic alternatives can significantly reduce prescription costs. Should a generic equivalent be available, this will be authorised in place of your prescribed medication unless your doctor has specified otherwise. If your application to the Momentum Africa Disease Management Programme is declined, the relevant medication can be regarded as acute medication, subject to Momentum Africa Scheme Rules and availability of funds. Signature Date 1 / 5
2 Section 3 - Medical Practitioner Details Surname Initials Type of Practitioner (e.g. general practitioner) Practice No Fax No Tel No Address Signature Section 4 - Risk Assessment To be completed by Doctor Date Height Weight Circumference of waist Relevant Disease Yes No Comments Diabetes Mellitus Type 1 Diabetes Mellitus Type 2 Thyroid Disease Abdominal Aortic Aneurysm Nephropathy / Renovascular / Microalbuminuria Dyslipidaemia Angina / Prior Myocardial infarction Cardiac Failure / Valvular Disease Peripheral Vascular Disease Dysrhythmia Hypertension Hypertensive Retinopathy / Other Stroke / Transient Ischaemic Attack Other Procedures Performed Prior CABG Organ Transplant Stent / Angioplasty / Angiogram Please supply details of Family History Lifestyle SMOKING STATUS Smoker Ex-Smoker Non-Smoker LIQUOR INTAKE Daily Weekly Occasionally Never EXERCISE Not Really >3 Hours per Week ALLERGIES (Specify) DETAILS OF HOSPITAL ADMISSIONS IN THE PAST YEAR 2 / 5
3 Cardiovascular Diseases Investigations required: Blood Tests: HB, Random Glukose, Total Cholestrol Urine: Microalbumin / Glukose Resting ECG If required: Stress ECG, Echocardiogram, Renal Ultrasound, Opthalmic Examination, X-ray, 24H Halter ECG Section 5 - Application for Hypertension When did this patient commence drug therapy? Date For hypertension diagnosed in the last six months and all newly diagnosed patients please supply two initial blood pressure readings (before drug therapy commenced) done at least two weeks apart in order to determine the stage of hypertension i) / mmhg Date ii) / mmhg Date Current BP reading (for all patients) / mmhg 24-Hour ambulatory blood pressure monitoring for newly diagnosed patients prior to starting medication, might be required. Section 6 - Application for Hyperlipidaemia Please attach Lipogram - To include total cholesterol, S-HDL, S-LDL, Total Triglyceride. The reimbursement of lipid modifying therapy for primary prevention is reserved for patients with a greater than 20% risk of an acute clinical coronary event in the last 10 years. This funding decision is in accordance with international guidelines. Please risk rate your patient as per the table and indicate your patient's score by circling the appropriate % risk below RISK FACTORS SCORE % RISK FACTORS Age (Years) SCORE WOMEN SCORE MEN SCORE WOMEN SCORE MEN TC (mmol/l) < > HDL-C (mmol/l) < > BP (mmhg) < 120 / / / / > 160/ > > > > 27 > 53 ADD UP RISK SCORES These risk factors should also be considered Obesity Family History Definite diagnosis of F.H. Source: SAMJ February 2000, Vol. 90, No. 2 Drug therapy indicated Smoker 2 2 Diabetic 2 2 Based on the information supplied, does your patient have a 20% or greater chance of a coronary event in the next ten years? We will not fund medication in patients with less than 20% risk of a coronary event in the next ten years. This is a funding decision to ensure the long-term sustainability of this benefit and does not in any way question your clinical decision. 3 / 5
4 Section 7 - Angiotensin-ll-blockers (ARB) Application Please fax the relevant pathology results to confirm the diagnosis of microalbuminuria Which ACE inhibitor(s) did the patient use? Please specify the period of use as well as the strength and dosage. Is the patient intolerant to ACE inhibitors? If the patient is intolerant to ACE inhibitors, which side effects did the patient experience? Please specify and describe the severity of the side effects. Specify which anti-hypertensive medicines, except ACE-inhibitors or angiotensin-ii-blockers, were used previously and indicate the reason why the medicine was discontinued. Please specify the medicine, duration of use, strength and dosage. Does the patient have any of the following diseases? Microalbuminuria (confirmed by three different microalbuminurea: creatinin ratio reports) Left ventricular hypertrophy Chronic renal disease A previous mycardial infarction Coronary artery stenosis Heart failure Please specify the angiotensin-ii-blocker for which you are applying ICD-10 Code Section 8 - Application for Diabetes When did the patient commence drug therapy for diabetes? Please attach the following bloodtests: Random/fasting Bloodglucose Initial fasting insulin HBA1C If Required: GTT For Insulin Resistance - Elevated fasting Insulin and normal glucose: Confirm with KWIK test The following criteria will apply for Diabetes Type 2 Fasting plasma glucose concentration 7mmol/l Casual plasma glucose concentration 1 1.1mmol/l Two hour post glucose or mmol during and Oral Glucose Tolerance Test (OGTT) Please note that based on cost and clinical guidelines, applications for glitazones and nateglinide require a motivation for use over conventional therapy from a specialist physician or endocrinologist. 4 / 5
5 Section 9 - Medication Details Application to register for chronic benefits for the first time or to register an additional condition) Diagnosis ICD10 Code Medication Prescribed Strength Directions For Use Qty per month Repeats other than ongoing Generic alternative Y/N Please state any other medicines taken on a regular basis (including non-prescription, homeopathic or traditional medicines) Please specify any previously approved medicines that must be discontinued and removed from the authorisation schedule Is the patient allergic to or has the patient had an adverse reaction to any medicines? If so, please state names of medicines Please state any conditions such as pregnancy (give due date), porphyria or other conditions treated by other medical practitioners Signature of Medical Practitioner Date Please ensure that the relevant reports and/or test results are included For completion of application form: Claim code / 5
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