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Application Form Confidential - samwumed

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Application Form Confidential v2.0.1

AfA does not dispense medication - Please fax this completed form to 0800 600 773 or email it to [email protected] This page needs to be completed by - The Applicant | Applications will be rejected unless signed by both Applicant and Doctor

Principal (Main) Member Details First Name

Surname

Medical Scheme

Gender

Membership No.

Option / Plan

MALE

FEMALE

MALE

FEMALE

Patient Details First Name

Surname

Dependant Code

Gender

ID Number

Date of Birth

D

D M M Y

Y

Y

Y

Treatment Support is a vital part of the AfA programme. Contact details must be supplied to enable us to provide you with this support. Confidential Email Postal Address for confidential mail Postal Code

Telephone(Home)

Fax No.

Telephone(Work)

Preferred form of communication What time of day is the best time for AfA to contact you?

EMAIL MORNING

FAX

POST AFTERNOON

Cellphone First Language Second Language

Next of kin or buddy who can be contacted if we cannot reach you (should know your HIV status) First Name

Telephone(Home)

Surname

Telephone(Work) Cellphone

I understand that all personal clinical information supplied to the Aid for AIDS (AfA) programme will be used to determine access to specific benefits for people with HIV infection. AfA will take all reasonable steps to maintain confidentiality. The programme’s medical staff will review this information in order to make recommendations regarding the provision of these benefits. Your doctor, however, retains responsibility for your care, irrespective of the benefits so authorised. I/we therefore, authorise any doctor, hospital, clinic, laboratory and/or medical facility in possession of any medical information regarding myself, the applicant or any dependant (also newly born baby), to provide the AfA programme with information that it may require. I warrant that the information in this application form is correct. I acknowledge that completion of the application form does not automatically entitle me to any benefits and that acceptance to the programme is within the sole discretion of AfA. I acknowledge that I am familiar with the conditions and benefits of the programme, notwithstanding representation by any other party; and agree to abide by and undertake to familiarize myself with the rules of the programme as amended from time to time. I acknowledge that benefits authorised by the AfA programme are subject to scheme rules and that non adherence to the programme could result in my benefits from this programme being cancelled. I acknowledge that I will be responsible for any co-payments as per scheme rules or payment for any medication and/or investigations not authorised by AfA. I understand that acceptance onto Aid for AIDS means that an AfA treatment support counsellor will contact me. I herewith authorise AfA and its agents/medical staff to disclose the medical information relevant to my HIV infection to third parties for the purpose of scientific, epidemiological and/or financial analysis without disclosure of my identity.

Patient’s Signature

Medical Aid No

Date

Dep Code

Patient Name

D

D M M

Y

Y

Y

Y

Page 1 of 4

Application Form Confidential v2.0.1

AfA does not dispense medication - Please fax this completed form to 0800 600 773 or email it to [email protected] This page needs to be completed by - The Doctor

Doctor Details Practice No.

Surname & Initials Email Address Postal Address Postal Code

Telephone

Preferred form of communication

EMAIL

FAX

Cellphone

POST

Fax

Clinical History When was HIV infection first diagnosed? (Please attach reports) Type of screening test

Test date

D

D M M

Y

Y

Y

Y

Type of confirmatory test

Test date

D

D M M

Y

Y

Y

Y

If YES, specify start date

D

D M M

Y

Y

Y

Y

YES - MTCT prophylaxis

YES - Other

Is the patient currently being treated for tuberculosis?

YES

NO

Has the patient previously been exposed to antiretrovirals?

NO

If YES, please provide details - Note: If the application is for a baby please list mom's previous ART history. Drugs

Start Date

End Date

Duration (Months)

Reason for discontinuation

Start Date

Current combination patient is taking

D

D M M

Y

Y

Y

Y

Please list all other medication the patient is taking, including prophylaxis YES

NO

Current heavy alcohol intake? (i.e. more than 4 drinks per day for a long period of time)

YES

NO

Current recreational drug use? (Cannabis, Cocaine, Ecstasy, LSD etc.)

YES

NO

Current depression or psychiatric illness?

YES

NO

YES

NO

Is the patient allergic to any medication? Sulphonamides

YES

NO

Other allergies?

If YES, specify

Information required to prevent adverse side-effects of certain drugs

If YES, specify treatment Current use of traditional or herbal remedies?

Medical Aid No

Dep Code

Patient Name

Page 2 of 4

Application Form Confidential v2.0.1

AfA does not dispense medication - Please fax this completed form to 0800 600 773 or email it to [email protected] This page needs to be completed by - The Doctor

Clinical Examination Weight

kg

Pregnant

Height

cm

If YES, specify:

WHO Clinical Staging

1

2

3

4

YES

Expected date of delivery

D

Expected mode of delivery

NVD

Expected date of C/S

D

Please tick disease below if Stage 3 or 4

NO

D M M

Y

Y

Y

Y

Y

Y

Y

Y

C/S

D M M

Clinical Stage 3 - Adult / Adolescent

Clinical Stage 4 - Adult / Adolescent / Paediatric

Unexplained severe weight loss (>10% of body weight)

HIV wasting syndrome (See Clinical Guidelines for definitions)

Unexplained chronic diarrhoea > one month

Pneumocystis pneumonia

Unexplained persistent fever > one month

Recurrent severe bacterial pneumonia

Persistent oral candidiasis

Chronic herpes simplex infection

Oral hairy leukoplakia

Oesophageal candidiasis

Pulmonary tuberculosis

Extrapulmonary tuberculosis

Severe bacterial infections (e.g pneumonia)

Kaposi’s sarcoma

Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis

Cytomegalovirus infection (retinitis or infection of other organs)

Unexplained anaemia,neutropaenia,chronic thrombocytopaenia

Central nervous system toxoplasmosis

Clinical Stage 3 - Paediatric

HIV encephalopathy

Unexplained moderate malnutrition

Extrapulmonary cryptococcosis including meningitis

Unexplained persistent diarrhoea (14 days or more)

Disseminated non-tuberculous mycobacterial infection

Unexplained persistent fever > one month

Progressive multifocal leukoencephalopathy

Persistent oral candidiasis (after first 6 weeks of life)

Chronic cryptosporidiosis

Oral hairy leukoplakia

Chronic isosporiasis

Acute necrotizing ulcerative gingivitis / periodontitis

Disseminated mycosis

Lymph node TB

Recurrent septicaemia (including non-typhoidal Salmonella)

Pulmonary TB

Lymphoma (cerebral or B-cell non-Hodgkin)

Severe recurrent bacterial pneumonia

Invasive cervical carcinoma

Symptomatic lymphoid interstitial pneumonitis

Atypical disseminated leishmaniasis

Chronic HIV-associated lung disease including bronchiectasis

Symptomatic HIV-associated nephropathy or symptomatic HIV-associated cardiomyopathy

Unexplained anaemia,neutropaenia,chronic thrombocytopenia Is there any degree of peripheral neuropathy? If YES, please specify

YES

NO

MILD

Is there any other significant clinical finding?

YES

MODERATE

SEVERE

NO

If YES, please specify Medical Aid No

Dep Code

Patient Name

Page 3 of 4

Application Form Confidential v2.0.1

AfA does not dispense medication - Please fax this completed form to 0800 600 773 or email it to [email protected] This page needs to be completed by - The Doctor

Special Investigation Results (Please provide copies of reports. Supply as many results as possible, including baseline results) Date Test Performed (DD/MM/YYYY)

CD4 count (cells / mm)

Additional Investigations

CD4% (must be provided for children)

Test Done?

Viral Load (copies / ml)

If yes, specify results

Test Date

Blood count(s) (Essential prior to approval of Zidovudine)

YES

NO

D

D M M

Y

Y

Y

Y

Baseline ALT (Essential prior to approval of Nevirapine

YES

NO

D

D M M

Y

Y

Y

Y

Serum creatinine/eGFR (Essential for patients with renal failure or prior to approval of Tenofovir)

YES

NO

D

D M M

Y

Y

Y

Y

Medication (Generic equivalents and fixed dose combination tablets will be authorised unless otherwise stated) Strength (e.g. 10mg)

Antiretroviral Therapy

Directions (e.g. 1 tds)

Period in use (months)

Period required (months)

Directions (e.g. 1 tds)

Period in use (months)

Period required (months)

Other Medication Required (Associated with the management of HIV) Diagnosis

Medicines

Strength (e.g. 10mg)

Acknowledgement by Examining Doctor Please Note: • Tariff code 0199 will only be paid for the first time completion of the application form. The form must be completed in full and signed by both the patient and the doctor. • Approval for ongoing antiretroviral therapy will only be considered if the result and date of a recent CD4 count and viral load is supplied. Only medication recommended in the Aid for AIDS Clinical Guidelines will be considered for reimbursement. Please refer to these guidelines or contact Aid for AIDS on 0800 22 7700, or at [email protected] for further information. Motivations will however always be considered. Please contact AfA for assistance if required. I certify that the above particulars are – to the best of my knowledge and belief – true and accurate, having conducted a personal examination and procured the tests and/or other diagnostic investigations referred to. I confirm that I have counselled the patient on the importance of adhering to medication and monitoring test regimens. I acknowledge that the Aid for AIDS programme will rely on such particulars when making any recommendations regarding payment for treatment to the relevant medical scheme. I acknowledge that telephonic discussions will be taped for medico-legal purposes.

Doctor's Signature Medical Aid No

Date Dep Code

Patient Name

D

D M M

Y

Y

Y

Y

Page 4 of 4

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Application Form Confidential - samwumed

Application Form Confidential v2.0.1 AfA does not dispense medication - Please fax this completed form to 0800 600 773 or email it to [email protected]

39KB Sizes 2 Downloads 0 Views

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