LARC Funding - Manual Form Please complete this form and forward with an invoice to WBoPHO
PROVIDER DETAILS Please Tick
Name: GP Practice:
Nurse
PATIENT DETAILS NHI:
DOB:
ELIGIBILITY Only 1 criteria is required - please tick applicable: 26 years old & under Māori or Pacific Lives in quintile 5 area Holds a community services card (CSC) Is at high risk of unplanned pregnancy and poor health and social outcomes. This Includes; wāhine with substance abuse issues, and wāhine in receipt of a statefunded benefit. OUTCOME: Jadelle Removal Initial LARC Consultation Irrespective of LARC outcome
Jadelle Insertion
IUCD Removal
IUCD Insertion
Duration of Consult (min):
Duration of Service (min):
Date of Consult:
Date of Service:
Please email to: GPSadmin@wboppho.org.nz or fax 07 577 - 3191 Or Post to:
WBoPPHO PO Box 13225 126 Eleventh Avenue Tauranga 3110 Invoices MUST include NHI, "LARC" and outcome (Jadelle Insertion/removal, IUCD Insert/removal or Pre-LARC consultation).