APPLY FOR CHRONIC MEDS ONLINE

Chronic Medication Benefit Application Form

SECTION 1: PRINCIPAL MEMBER INFORMATION.

Where would you like your medicine delivered?

SECTION 2: IMPORTANT PATIENT INFORMATION.

Do you smoke?
If yes - state type, quantity and frequency

SECTION 3: RULES APPLICABLE TO CHRONIC MEDICATION BENEFIT (CMB)

Cardiovascular Diseases:
Cardiac Failure
Cardiomyopathy
Coronary Artery Disease
Dysrhythmias
Hypertension
Hyperlipidaemia
Additional Information - Hyperlipidaemia
If yes, how many cigarettes a day?
Risk Factors: (Please indicate where applicable)
Angina/Myocardial Infarction
Angioplasty/Stent
Cerebrovascular Accident (CVA)
Family History
Peripheral Vascular Disease
Transient Ischaemic Attack
Endocrine System:
Addison’s Disease
Diabetes Insipidus
Diabetes Mellitus 1
Diabetes Mellitus 2
Hypothyroidism
Fasting Glucose:
Hypothyroidism
Respiratory Diseases
Asthma
Bronchiectasis
Chronic Obstructive Pulmonary Disease (COPD)
Initial FEV 1 (spirometry report):
Auto-Immune Diseases
Multiple Sclerosis*
Clinical / Laboratory Supporting Documentation
*Please Note that confirmation of diagnosis by MRI scan is required from a Neurologist. Neurologist Practice Number:
Systemic Lupus Erythematosus
Clinical / Laboratory Supporting Documentation
Rheumatoid Arthritis*
Clinical / Laboratory Supporting Documentation
Gastrointestinal Diseases
Chron’s Disease*
Clinical / Laboratory Supporting Documentation
Ulcerative Colitis
Clinical / Laboratory Supporting Documentation
Neurological Diseases
Epilepsy
Clinical / Laboratory Supporting Documentation
Parkinson’s Disease
Clinical / Laboratory Supporting Documentation
Ophthalmological Diseases
Glaucoma
Clinical / Laboratory Supporting Documentation
Other Diseases
Chronic Renal Disease*
Clinical / Laboratory Supporting Documentation
Glomerular Filtration rate/Creatinine clearance
HIV
Clinical / Laboratory Supporting Documentation

SECTION 4: CURRENT MEDICATION REQUIRED

If yes, please state:
MEDICATION HISTORY IF DIFFERENT FROM CURRENT

SECTION 5: DOCTOR’S DETAILS

Practice Physical Address?
Address
Copyright © 2023 Acumen Health, All Rights Reserved.
Website Design by AJ
envelope linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram