CMH Maternity Co-Payment Funding Voucher

CMH POAC Funded Maternity Co-Payment Voucher

For eligible women birthing in Counties Manukau DHB
This funding voucher is valid for the duration of this entire pregnancy for maternity-related ultrasound scans for women scheduled to birth in a Counties Manukau facility.

All dating scans are excluded.

Co-payment funding of nuchal and anatomy scans is available for women who hold a valid Community Services Card AND for all under the age of 18.

Ensure the CSC number is applied to the radiology request form or the radiology provider informed at appointment attendance.
Date*

DayMonthYear
Date
Eligibility Confirmation*

This patient is eligible for maternity health funding and is scheduled to birth in a CMH facility
Patient has a Community Services Card*

YesNoDon't know
Community Services Card Number
If known at time of voucher request
EDD*

DayMonthYear
Date
Referrer name*
Referrer designation

LMC/MidwifeGeneral PracticeSecondary ServicesOther
Referrer phone contact*
Referrer email*
to receive copy of submission
Patient NHI*
Date of birth*

DayMonthYear
Date
Patient name*

First NameLast Name
Patient phone number*
Ethnicity*
NOTES
Should be Empty:

CMH POAC Funded Maternity Co-Payment Voucher