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: Initial LARC Consultation
Jadelle Insertion
Jadelle Removal
Irrespective of LARC outcome
IUCD Insertion
IUCD Removal
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).
Clear Form