COVID-19 Pharmacy Services Record Claim Form

COVID-19 Care in the Community

Paxlovid Community Pharmacy Services
Eligibility:*

Confirmed meets antiviral criteria
Date Of Service*

DayMonthYear
Please ensure this date is the actual date of service provision
Pharmacy Name*
If pharmacy name does not appear on the list, email deannaw@easthealth.co.nz or text 021665521
HPI Facility ID*
Pharmacy Email
For emailed confirmation of submission
Patient NHI*
Patient Name*

First NameLast Name
Date confirmed positive or symptoms started:*

DayMonthYear
Date
Consultation and Medicine Supply
$5 Prescription co-payment collected from patient*

Yes $5 co-payment was paid by patientNo co-payment collected
Paxlovid Supply*

Supply by pharmacist direct supplySupply by pharmacist pursuant to a prescription
Total Payable (excl GST)
Should be Empty:

COVID-19 Care in the Community