CHRONIC MEDICINE Tel: 086 000 2378

Fax: (012) 339 9944

APPLICATION FORM medicine@bestmed.co.za
www.bestmed.co.za

Chronic Disease List

Paragraphs 1 to 3 must be completed by the member.
Paragraph 4 to 6 must be completed by a medical practitioner.

1. PARTICULARS OF PRINCIPAL MEMBER

Surname and initials: Member number:

Address:

Date of Birth: Telephone number: (w)

Telephone number: (h) E-mail:

Cellphone number: Fax:

2. PARTICULARS OF THE PATIENT

Surname and initials: Cell phone number:

Date of birth: Height: Sex: M F

Does the patient YES NO Weight kg

smoke?

Hysterectomy YES NO

E-mail: ……………………………………………………………………………………………………………

3. PATIENT’S CONSENT:
I hereby give permission to the doctor or any other service provider to state the diagnosis and mention any other information
relating to my condition/s on the form or questionnaire. I understand that this information will remain confidential at all times.

Signature: Date:

4. CLINICAL QUESTIONNAIRE: IMPORTANT

a) Please complete all the appropriate sections in the following clinical questionnaire. For medicine used for Rheumatoid arthritis an
additional questionnaire must be obtained from BESTmed and completed:
b) Medicine application for Epilepsy must be accompanied by EEG report.
c) Please attach all the requested pathology and medical reports.

PLEASE NOTE:
Non-CDL chronic and/or CDL chronic benefits are granted according to the BESTmed formulary per condition
per benefit option. The formularies are available on the BESTmed website at www.bestmed.co.za under
“Healthcare Information”.
A. HYPERTENSION, HYPERLIPIDAEMIA AND DIABETES MELLITUS
Does the patient suffer from any of the following sickness conditions? Mark with an X where applicable.

SICKNESS CONDITIONS
Diabetes type 1 Diabetes type 2

Micro-albuminuria or GFR < 60 ml/min Stroke/TIA

Left ventricular hypertrophy Heart failure

Hypertensive retinopathy Peripheral arterial disease

Chronic renal disease Family history of heart attacks

Familial hyperlipidaemia Coronary artery disease (eg angina, myocardial

infarction, prior artery bypass graft, angioplasty**)
**Attach all relevant medical reports.

HYPERTENSION QUESTIONNAIRE

BLOOD PRESSURE READING READING DATE

At diagnosis
Current

Copies of pathology reports are COMPULSORY for the application to be processed and in the event of changes to
current therapy or dosages.

HYPERLIPIDAEMIA Baseline lipogram values: Test date

QUESTIONNAIRE
Total
Triglycerides HDL LDL
Cholesterol
Lipogram values on treatment: Test date
Total
Triglycerides HDL LDL
Cholesterol
Does the patient suffer from any of the following
YES NO DETAILS
conditions?
Hypo- or hyperthyroidism?

History of ischaemic heart disease?

History of peripheral artery disease?

History of TIA and/or stroke?

Family history of hypercholesterolemia?

If yes: Father myocardial infarction before the age
of 55 years?
If yes: Mother myocardial infarction before the age
of 65 years?
Were any lifestyle changes made?

Does the patient follow an exercise programme?

Does the patient follow a special diet?

Were there any changes in weight?

Serum-creatinine level or
End stage renal failure?
GFR:
DIABETES MELLITUS QUESTIONNAIRE

Is the patient newly diagnosed with diabetes? Yes No

Type of diabetes? Type 1 Type 2

Baseline pathology values:

Fasting blood glucose: HbA1c: Date of test:

Most recent pathology values:

Fasting blood glucose: HbA1c: Date of test:

B. OSTEOPOROSIS QUESTIONNAIRE
.
Copies of earliest and latest DEXA densitometry must be attached.

Age when menopause was diagnosed

Is the patient currently on hormone replacement therapy? Yes No

Date of commencement of hormone replacement therapy

Date
(if applicable)?

Date when oophorectomy was done (if applicable). Date

Details of previous bone fractures.

Details of long term cortisone therapy, if any.

What is the patient’s BMI?

Any alcohol intake? If yes, how many units per < 4 units per week:
week? ≥ 4 units per week:

Any medical condition(s) resulting in prolonged

immobility?

C. ASTHMA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AND CHRONIC

ALLERGIC RHINITIS:
COPD QUESTIONNAIRE
NB: Results of lung function test must be attached. If the application is for home oxygen, then the blood gas report
is required. Please mark applicable answer.
Date when COPD was diagnosed.

How many times was the patient hospitalised for COPD in the past 3 years? 0 <3 >3
How many times did the patient receive emergency treatment for COPD
in the past 3 years? 0 <3 >3
Frequency of oral cortisone treatment in the past year? Never Once 3 or > Chronic
Date of lung function test performed. Test date:

FEV1 (% of calculated), predicted ≥ 80% 79–50% 49–30% < 30%

FEV1/FVC value of the report

FEV1 post-bronchodilator value of the report

Does the patient suffer from any of the following conditions? Heart condition Yes No ICD-10:

Respiratory failure Yes No ICD-10:

 ASTHMA QUESTIONNAIRE

Date when asthma was diagnosed.

PEF (% of calculated), predicted > 80% 60 - 80% <60%

How often does the patient experience asthma attacks?
≤ 2 / week 2-4 / week > 4 / week Continuous

How often does the patient experience night-time asthma ≤ 2 / month > 2 / month > 1 / week Frequently
symptoms?
How many times was the patient hospitalized for asthma in the 0 <3 >3
past 3 years?
How many times did the patient receive emergency treatment
0 <3 >3
for asthma in the past 3 years?
Frequency of oral cortisone treatment in the past year?
Never Once 3 or > Chronic

CHRONIC ALLERGIC RHINITIS QUESTIONNAIRE

Date when allergic rhinitis was first diagnosed.

Specify any diagnostic tests performed.

Has the patient previously undergone a sinus operation? YES NO

If yes: at what age was this operation performed?

D. PSYCHIATRIC QUESTIONNAIRE
.
A psychiatrist must complete this application form.

Initial diagnosis and date of diagnosis:

Current ICD-10 code:
1) CURRENT DIAGNOSIS ACCORDING TO DSM4 CRITERIA:
Axis i:
Axis ii:
Axis iii:
Axis iv:
Axis v:
2) MEDICINE HISTORY FOR PSYCHIATRIC CONDITION:

Date started Medicine Period used and reason for stopping medicine (if applicable)

3) HOSPITALISATION HISTORY FOR PSYCHIATRIC CONDITION:

Date Length of stay Hospital Reason for hospital stay

Psychiatrist Practice number

IMPORTANT:
Indicate for every ICD-10 code on the table if the required authorisation is for the non-CDL* chronic benefit or the CDL chronic benefit. (* The CDL benefit is only applicable for diseases on the Chronic Disease List
according to legislation.)
Only medicine on the relevant medicine formulary will qualify for the specific benefit.
The ICD-10 code must be appropriate to qualify for CDL benefits.

5. MEDICINE BENEFITS APPLIED FOR

(Please list all the medicine that is used for a specific sickness condition. This new authorisation will supersede all previous authorisations for the same condition.)

. Non-CDL chronic benefit: CDL chronic benefit:

i) Choose medicine from the formulary for the condition i) Choose medicine from the formulary for the condition
ii) 15% co-payment ii) No co-payment if formulary medicines are chosen

PATIENT NAME AND SURNAME:__________________________________ MEMBERSHIP NUMBER:____________________________________

NAME & STRENGTH OF MEDICINE PRESCRIBED HOW LONG HAS PATIENT

QUANTITY HOW MANY
ICD-10 CODE AND SELECTED FROM THE APPROPRIATE DOSAGE BEEN ON THIS MEDICINE?
PER MONTH REPEATS
BESTMED FORMULARY

List medicine to be stopped or discontinued.

6. DECLARATION OF ATTENDING DOCTOR.

I declare that to the best of my knowledge, all the above information is true and accurate, based on the examinations and tests performed on this patient.

Surname and initials: Cell phone number:

Telephone number: E-mail:

Discipline: Fax:
.
Doctor’s signature Practice number Date