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 DHB facility.

All dating scans are excluded.

Nuchal and Anatomy co-payment funding is available for women who hold a valid Community Services Card. The number must be applied to the radiology request form or the radiology provider informed at appointment attendance.
Date *

Day Month Year
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 or is a beneficiary *

Yes No Don't know
EDD *

Day Month Year
Date
Referrer name *
Referrer designation

LMC/Midwife General Practice Secondary Services
Referrer phone contact *
Referrer email *
to receive copy of submission
Patient NHI *
Date of birth *

Day Month Year
Date
Patient name *

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

CMH POAC Funded Maternity Co-Payment Voucher