GEMS PMB Form & Motivation Letter

PMB Benefit Application
Patients Details
Title
Initials
First Name
Surname
malefemale
Pronoun
Date of birth*
MonthDayYear
Date
Age in years
Age in days
ID or passport number
Dependent Code
Option/Plan
Membership number
Cell number
Please enter a valid phone number.Format: (000) 000-0000.
Patients Email
example@example.com
Date
DayMonthYear
Date
Patients Signature
Clear
2. Application
(Healthcare professional to complete)
Date of diagnosis
DayMonthYear
Date
Rows Condition ICD-10 Code Procedure description Quanitity required Procedure codes Motivation
Row 1
Row 2
Row 3
Row 4
Row 5
Row 6
Row 7
Physiotherapists Name & Surname
First NameLast Name
Physiotherapist Email*
example@example.com
Signature of healthcare professional
Clear
Date
DayMonthYear
Date
Motivation Letter Information
Clinical Summary & Background (What happened to the patient?)
Presents with the following issues currently:
Progress made during sub-acute stay including objective scores from admission to discharge
Goals for OPD therapy
Treatment Plan for OPD
bed bound, fully dependent on all bed mobilityable to roll from side to side in bedable to move around in bedable to change body position in bedable to mobilise from lying to sittingable to maintain body position in sittingable to sit over the edge of bedable to transfer from bed to chairable to transfer from chair to bedable to transfer to wheelchair from bedable to sit to standable to standable to march on the spotable to take a few steps (3-5)able to walk within bedroomable to walk to bathroomable to walk short distances (50m)able to walk short distances (100m)able to walk short distances (200m)able to walk short distances (300m)able to walk 500metresable to walk 800metresable to walk on different surfacesable to walk long distances (1km)able to walk around obstaclesable to walk on outdoor terrainsable to do a step up on a stepable to climb a few stairs (3-5) using hand railingable to climb a few stairs (3-5)able to climb a full flight of stairs using hand railingable to climb a full flight of stairsable to climb stairs one step at a time using hand railingable to climb stairs one step at a timeable to confidently climb stairs with alternating stepsable to climb stairs, even when carrying itemsable to independently move around in wheelchairable to sit independently in wheelchairOther
no assistive devicea walking sticka walking framea rollator1 x Elbow Crutch2 x Elbow Crutchesa two-wheel Walkera four-wheel Walkera Knee Scootera wheelchaira nordic walking sticka quadrapoda hoista transfer boardOther
independentlywith supervisionwith minimal assistance from 1 personwith moderate assistance from 1 personwith moderate assistance from 2 peoplewith maximal assistance from 1 personwith maximal assistance from 2 peoplefully dependentOther
bed bound, fully dependent on all bed mobilityable to roll from side to side in bedable to move around in bedable to change body position in bedable to mobilise from lying to sittingable to maintain body position in sittingable to sit over the edge of bedable to transfer from bed to chairable to transfer from chair to bedable to transfer to wheelchair from bedable to sit to standable to standable to march on the spotable to take a few steps (3-5)able to walk within bedroomable to walk to bathroomable to walk short distances (50m)able to walk short distances (100m)able to walk short distances (200m)able to walk short distances (300m)able to walk 500metresable to walk 800metresable to walk on different surfacesable to walk long distances (1km)able to walk around obstaclesable to walk on outdoor terrainsable to do a step up on a stepable to climb a few stairs (3-5) using hand railingable to climb a few stairs (3-5)able to climb a full flight of stairs using hand railingable to climb a full flight of stairsable to climb stairs one step at a time using hand railingable to climb stairs one step at a timeable to confidently climb stairs with alternating stepsable to climb stairs, even when carrying itemsable to independently move around in wheelchairable to sit independently in wheelchairOther
no assistive devicea walking sticka walking framea rollator1 x Elbow Crutch2 x Elbow Crutchesa two-wheel Walkera four-wheel Walkera Knee Scootera wheelchaira nordic walking sticka quadrapoda hoista transfer boardOther
independentlywith supervisionwith minimal assistance from 1 personwith moderate assistance from 1 personwith moderate assistance from 2 peoplewith maximal assistance from 1 personwith maximal assistance from 2 peoplefully dependentOther
bed bound, fully dependent on all bed mobilityable to roll from side to side in bedable to move around in bedable to change body position in bedable to mobilise from lying to sittingable to maintain body position in sittingable to sit over the edge of bedable to transfer from bed to chairable to transfer from chair to bedable to transfer to wheelchair from bedable to sit to standable to standable to march on the spotable to take a few steps (3-5)able to walk within bedroomable to walk to bathroomable to walk short distances (50m)able to walk short distances (100m)able to walk short distances (200m)able to walk short distances (300m)able to walk 500metresable to walk 800metresable to walk on different surfacesable to walk long distances (1km)able to walk around obstaclesable to walk on outdoor terrainsable to do a step up on a stepable to climb a few stairs (3-5) using hand railingable to climb a few stairs (3-5)able to climb a full flight of stairs using hand railingable to climb a full flight of stairsable to climb stairs one step at a time using hand railingable to climb stairs one step at a timeable to confidently climb stairs with alternating stepsable to climb stairs, even when carrying itemsable to independently move around in wheelchairable to sit independently in wheelchairOther
no assistive devicea walking sticka walking framea rollator1 x Elbow Crutch2 x Elbow Crutchesa two-wheel Walkera four-wheel Walkera Knee Scootera wheelchaira nordic walking sticka quadrapoda hoista transfer boardOther
independentlywith supervisionwith minimal assistance from 1 personwith moderate assistance from 1 personwith moderate assistance from 2 peoplewith maximal assistance from 1 personwith maximal assistance from 2 peoplefully dependentOther
Currently struggling with the following ADLs
Expected outcomes from physiotherapy
swellingjoint stiffnesscontracturesrespiratory infectionssevere disabilitymuscle weaknessimpaired balancerisk of fallspaininfection riskmuscle atrophyjoint stiffnesspressure ulcersblood clotsrespiratory issuesmental health declinefalls riskchronic painreduced independencedecreased mobilityspasticitycontracturespressure soresmalnutritiondeep vein thrombosisseizuresshoulder subluxationnonunionmalunionrespiratory failurechronic hypoxiadecreased lung capacityatelectasispulmonary infectionsreduced exercise toleranceanxiety or depressionpoor quality of lifeincreased hospitalizationsphantom limb painpoor prosthetic fittinggait abnormalitiessocial isolationautonomic dysreflexiaosteoporosisloss of functional skillspoor cardiovascular healthdelayed healingscarring and adhesionspoor coordinationOther
Patients Name:
{title} {firstName8} {surname}
Medical Aid:
GEMS
Membership No.:
{membershipNumber}
{title} {firstName8} {surname} is a {ageIn247}-year-old {gender}. {pronoun} was referred to our practice for out-patient physiotherapy to continue with intensive rehabilitation, focusing on optimizing recovery, functional independence, and overall quality of life.
{clinicalSummary}. {pronoun} currently presents with the following issues:
{typeA276}
Pre-morbid level of function:
Before the patient was admitted to the hospital, they were {baselineMobility} using {typeA256} {typeA257}.
{pronoun} currently struggles with the following ADLs:
{typeA275}
Highest level of function currently:
On assessment they were {assessmentMobility} using {mobilityDevice} {assessmentDependence}.
{progressMade}
Goals of physiotherapy as an out-patient are as follows:
{typeA}
Goal level of function to achieve from out-patient physiotherapy:
Our main goal is to ensure that the patient can {goalMobility} using {goalMobility262} {goalDependence}.
Treatment plan includes:
{typeA279}
Expected Outcomes following physiotherapy:
{typeA277}
To achieve the desired outcomes and goals, the patient requires approval of their PMB authorisation for out-of-hospital physiotherapy benefits.
This authorisation would ensure we reach the desired therapeutic goals and prevent any further implications or side effects relating to their condition. This rehabilitation will help avoid complications, including {possibleComplications}.
By optimising the rehabilitation process, we aim to reduce the likelihood of further medical interventions, readmissions, or long-term impairments, ensuring the patient returns safely to their daily activities with the best possible outcomes.

{physiotherapistsName}
Email: tokai@tokai.physio
Contact: +2787 138 6718
Website: www.tokai.physio
Practice Number: 0959979
Should be Empty:

Rows	Condition	ICD-10 Code	Procedure description	Quanitity required	Procedure codes	Motivation
Row 1
Row 2
Row 3
Row 4
Row 5
Row 6
Row 7

Patients Name:	{title} {firstName8} {surname}
Medical Aid:	GEMS
Membership No.:	{membershipNumber}

PMB Benefit Application

Patients Details

2. Application

Motivation Letter Information

Pre-morbid level of function:

{pronoun} currently struggles with the following ADLs:

Highest level of function currently:

Goals of physiotherapy as an out-patient are as follows:

Goal level of function to achieve from out-patient physiotherapy:

Treatment plan includes:

Expected Outcomes following physiotherapy: