Cellulitis - Claim Form Start Date NHI:
Case Number:
Practice: ACC
Non-ACC
Redirect
AHC completed part of this Treatment
ORAL Treatment: Grade 2
Grade 3
(up to 2 follow ups)
(up to 5 follow ups)
Number of follow up consults completed at Practice (Can only claim for one GP or Nurse consult per day) Nurse Consults
GP Consults
Phone Consults
Please do not complete both sections
IV Treatment: Following 3 days of IV antibiotics no follow up consults are funded when the patient commences oral therapy. One Dose per Day
First Day Reason for more than 3 days
Two Doses per Day
Final Day
Total No. of days complete at practice
(include first and final dose if completed at practice)
(please contact the PHO if the patient requires more than 3 days, 07 571 7161)
PMS Invoice Detail Number
Date
Amt(incl)
Reset Form Please complete this form and forward to WBoPHO
Alternatively Email : adsadmin@wboppho.org.nz Fax Number: 07 577 - 3191 Postal Address: PO Box 13225, Tauranga 3110