Dr E Scott INC | West Med Medical Centre Sanctuary

(HCP) Medical Practitioner Out of Hospital Infusion referral & Authorisation Request 

Patient Details
Referring Doctor Practice Details
Infusion Treatment Requested
ICD 10 Codes
Diagnosis & Motivation
I hereby refer the above-named patient to West Med Medical Centre – Dr E Scott Inc, for the administration of out-of-hospital infusion therapy, as clinically indicated. I request that West Med Medical Centre liaise directly with the patient’s medical aid to obtain pre-authorisation for both the medication and the infusion procedure. I confirm the following: The prescribed infusion medication must be procured directly by West Med to ensure eligibility for medical aid benefits. Only medications with a registered brand name, valid NAPPI code, and reference number will qualify for medical aid reimbursement. A comprehensive clinical report outlining the infusion details, patient response, and any relevant findings will be provided to me, the referring practitioner, to support ongoing continuity of care. Please contact me should any further information be required.