Southern Cross Medical Care Society

Level 1, Ernst & Young Building

2 Takutai Square, Auckland 1010
Private Bag 99934, Newmarket, Auckland 1149
Phone 0800 800 181
www.southerncross.co.nz/society

Mr Tiery Laborde
Flat 14, 1 Tasman Street
Mount Cook
Wellington 6021

23 February 2018
Membership number 23111100

We need more information to assess your request for approval

Dear Mr Laborde

Thank you for your request for approval for the following healthcare service:

Name Tiery Laborde (born 09 April 1986)

Healthcare service All treatments/ Investigations relating to dry skin on eye lids, under
eyesitchy, swollen eye lid
We need more information from your primary care provider (for example your GP) to assess
this approval.

What you need to do

Please give the enclosed letter and forms to your primary care provider and ask them to
complete and return them to us as soon as possible.

Your primary care provider may ask for your written authorisation to release information to us.
This is not something we require. Please speak to your provider if you have any questions
about this.

Privacy of information
We will use this information in accordance with the Privacy Act 1993 and the privacy statement
in your policy. Specifically, we will collect information to process the request for approval (and
any consequent claim made under your policy).

If the information from the primary care provider reveals a pre-existing condition that has not
been disclosed to us previously, we may add this to your policy.

FFS_PCR
Any questions?
If you have any questions please call our Claim Approvals team on 0800 800 181. We’re here
to help from 8am to 6pm, Monday to Friday.

Yours sincerely

Farzana Hassan
Claim Approvals Consultant- Member Services
Southern Cross Health Society
 23 February 2018

Request for information

Dear General Practitioner

We have received a request to approve cover for your patient Tiery Laborde of Flat 14, 1
Tasman Street Mount Cook, Wellington 6021 for the following healthcare service which is
booked to take place on 23 February 2018:
Healthcare service All treatments/ Investigations relating to dry skin on eye lids, under
eyesitchy, swollen eye lid
In order for us to assess this request, we need more information from you.

What we need from you

· please complete the enclosed medical report
· provide copies of any other relevant information you hold in relation to the condition
requiring the healthcare service, particularly letters of referral to specialists and their
reports to you
· scan and email the report and copies to apadmin@southerncross.co.nz. Alternatively you
can return by post to PA Admin Team, Southern Cross Health Society, Private Bag 99934,
Newmarket, Auckland 1149, Freepost Authority 1440
· if the procedure is booked to take place within the next 10 days, please respond by email.

Reimbursement for your time

We will pay a contribution of up to $50 (including GST) towards your costs (your time and
materials) for completing and sending this report. Please enclose your invoice when you send
the report to us.

Your patient’s privacy

In accordance with the Privacy Act 1993, the terms of Tiery’s policy authorise the collection of
this information and disclosure to us. We therefore don’t require written consent from your
patient for you to send us the above.

Any questions?
If you have any questions or would like more information please contact us on 0800 800 181.
We’re here to help from 8am to 6pm, Monday to Friday.

Yours sincerely

Farzana Hassan
Claim Approvals Consultant- Member Services
Southern Cross Health Society
Primary care report
Please complete and return this report and your supporting documents (as set out in our
letter). You can return by:
· email - scan and send to apadmin@southerncross.co.nz
· post – send to PA Admin Team, Southern Cross Health Society, Private Bag 99934,
Newmarket, Auckland 1149, Freepost Authority 1440.

Primary care provider: General Practitioner

Member name: Tiery Laborde

Membership number: 23111100

Address: Flat 14, 1 Tasman Street Mount Cook, Wellington 6021

Date of birth: 09 April 1986

Provider: Ian Coutts

Date of procedure: 23 February 2018

Information is required about the following conditions/medications/procedures:

All treatments/ Investigations relating to dry skin on eye lids, under eyesitchy, swollen eye lid

Please be as detailed as possible when answering the questions below.

On what date did this patient first consult you or your practice about signs/symptoms relating
to the conditions/medications/procedures above?

Please list all of the signs/symptoms? (please include comments about recurrent conditions)

Report page 1
When was your patient first aware of each sign/symptom, according to the history held by your
practice?

Please list the names of the prescribed medications relating to this condition /procedure and
the date(s) these were originally prescribed.
Medication Date prescribed

How long has Tiery Laborde been your patient?

If the patient’s notes have been transferred from another practice, please confirm:
· how many years of notes were transferred, and
· that these notes were reviewed when filling out this report.

Checklist of things to include:

£ completed primary care report
£ the referral letters to the specialist
£ all of the specialist’s reports back to you
£ all previous patient notes that relate to the condition requiring the healthcare service
(including both physical copies as well as those that are held electronically, and any from
previous practices that the patient has attended)
£ any other supporting documentation, ie imaging/diagnostic reports
£ your invoice for time and expenses.

IMPORTANT: Delayed or incomplete information may affect our ability to make a decision in
time for the booked procedure date. If we don’t receive everything we need to make our
approval decision, we may request more information. Often, this is in the form of clinical notes.

I declare that the information I have disclosed is true and complete:

Primary care provider’s name Date

Primary care provider’s signature Contact phone number

Practice stamp
Thank you for providing this information. Please see the checklist above to make sure
this report is accompanied by all other necessary documentation.

Report page 2