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, excluding dating scans.

Voucher is for eligible women who are planned to birth in a CMH facility.
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