e x c e l l e n c e y o u c a n t r u s t
APPLICATION FORM MedICINe RISK MANAGeMeNT
I authorise my medical practitioner to furnish and/or disclose to the Medicine Management Programme any fact relating to this application as well as any additional information that may be required from time to time. (Remember that your medical practitioner bears the responsibility of prescribing the medication for you, irrespective of the benefit authorised.)
date D D M M Y Y Y Y
TO be COMPLeTed by The ATTeNdING MedICAL PRACTITIONeR
TO be COMPLeTed by The ATTeNdING MedICAL PRACTITIONeR (CONTINued)
PLeASe NOTe ThAT IN ORdeR TO COMPLy wITh The GOveRNMeNT RISK equALISATION FuNd (ReF), The ReCeIPT OF CeRTAIN CLINICAL INFORMATION IS MANdATed PRIOR TO The AuThORISATION OF ChRONIC MedICINeS. TheSe INCLude:E Chronic Obstructive Airways disease: .Lung Function TestsE Chronic Renal Failure: .Creatinine Clearance/Glomerular Filtration RateE Haemophilia: .Factors VIII and IX blood levelsE Hyperlipidaemia: .Lipogram*
IN AddITION, MedICINe RISK MANAGeMeNT RequIReS CeRTAIN SPeCIAL INveSTIGATIONS TO exPedITe The ChRONIC AuThORISATION PROCeSS. ThIS INCLudeS, buT IS NOT LIMITed TO, The FOLLOwING:E Long-acting insulin analogues, glitazones: .HbAlc and motivationE Bisphosphonates and other agents for osteoporosis: .Bone Mineral density and motivationE Angiotensin Receptor Blockers (ARBs): .Motivation
* In primary prevention patients requesting lipid-modifying therapy (e.g. statins), reimbursement is reserved for patients with a greater than 20% risk of an acute clinical coronary event within the next 10 years, as calculated by the Framingham Risk Calculation and in accordance with locally and internationally accepted treatment guidelines. Please note that generic simvastatin is the preferred statin in these instances.
Please indicate below where you agree to a generic substitution and provide your preferred medication name. Chronic medicine is subject to generic reference pricing.
MedICATION PReSCRIbed (Please use block letters)
detailed diagnosis and date Name (trade name or
MedICATION STOPPed (Please use block letters)
If your patient has one or more of the following chronic conditions, he/she may qualify for additional services. Please indicate which condition(s) he/she has by placing an “X” next to the applicable condition.
I hereby acknowledge that the scheme has appointed Qualsa Healthcare (Pty) Ltd as the administrator of the programme and that any prescribed medical treatment shall be the sole responsibility of my medical practitioner.
I understand that the information provided on this form shall be treated as confidential and will not be used or disclosed except for the purpose for which it has been obtained.
Whilst Qualsa undertakes to take all reasonable precautions to uphold the confidentiality of information disclosed to it, I am aware that my medical scheme and practitioner (where necessary) shall also gain access to the same information. I shall therefore not hold Qualsa liable for any claims by me or my dependants arising from any unauthorised disclosure of my personal information to other parties.
I hereby certify that the information provided is true and correct.
D D M M Y Y Y Y RetuRn addRess: Medicine Risk Management, PO Box 32210, Braamfontein 2017 or fax 0860 101 480
INTERLOCUÇÕES ENTRE PSICOLOGIA E EDUCAÇÃO QUEIROZ, Daisy Seabra de – FAFIMA GT: Psicologia da Educação /n.20 Agência Financiadora: Não contou com financiamento. Introdução As questões e reflexões discutidas no presente texto referem-se à interface da Psicologia com a Educação na atualidade. As aproximações complexas entre ambas remontam aos primórdios da