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For referring practitioners

Practitioner IUD referral form

Refer a patient to West-Med for Comfort IUD insertion under sedation and analgesia. We will liaise with the patient's medical aid for pre-authorisation and send you a clinical report afterwards.

Before you start

What we need from you

  • The patient's identity and contact details, so we can arrange the appointment directly with them.
  • The device requested, by brand and NAPPI code. Only devices with a registered brand name, NAPPI code and reference number are eligible for cover.
  • A motivational ICD-10 code alongside Z30.1, which is what the scheme assesses the authorisation against.
  • The patient's scheme, membership number and how long they have been on the plan.

Questions about a referral, or need to send something we have not asked for here? Call 021 490 4380 and ask for the IUD coordinator.

Patient details

Referring doctor practice details

Device requested

Diagnosis and motivation

Patient medical scheme details

Referral confirmation

I hereby refer the above patient to West Med Medical Centre – Dr E Scott Inc for the insertion of an intrauterine device (IUD) under sedation and/or analgesia. I request that West Med Medical Centre liaise with the patient’s medical aid to obtain pre-authorisation for both the device and the procedure.

I confirm that:

  • •The IUD must be ordered directly by West Med in order for medical aid benefits to apply.
  • •Only devices with a registered brand name, NAPPI code and reference number will be eligible for cover.
  • •A detailed clinical report of the IUD insertion will be provided to me as the referring doctor for continuity of care.