APPLICATION FOR MEMBERSHIP

Transcription

1 MEMBERSHIP NUMBER (FOR OFFICE USE ONLY) Contact details: Customer Service Department Physical address: 101 De Korte Street, Braamfontein APPLICATION FOR MEMBERSHIP PLEASE COMPLETE THE FORM IN BLOCK LETTERS AND RETURN IT TO YOUR HUMAN RESOURCES DEPARTMENT. It is imperative that all sections of this application form be completed in full. Failing to do this may cause a delay in the processing of the application. 1. APPLICANT S INFORMATION Identity number (Copy of identity document required.) Title Sex Male Female Language English Afrikaans Marital status Single Married Co-habitating (domestic partnership) Divorced Widow/er Civil union partner Date of marriage or civil union (attach a copy of the certificate): Telephone numbers Work Home Cell address (W) address (H) Postal address Code Residential address 2. EMPLOYMENT DETAILS Employer group name Code Employment start date Employee number 3. BANK DETAILS FOR DIRECT DEPOSITS OR REFUNDS Please complete this section in full. Banking details are required for the purpose of paying out refunds due to members and for the collection of membership contributions. Name of account holder Account number Branch Name of bank Branch code Account type Current/Cheque Savings Transmission 1

2 4. OPTION AND SALARY DETAILS A. MEMBERSHIP COMMENCEMENT DATE B. PLAN SELECTION (PLEASE SELECT YOUR PLAN BY MAKING AN X IN THE RELEVANT BLOCK) State Plus Network State Plus Own Choice Private Network C. GROSS MONTHLY INCOME R (Proof of income is required for pensioner members) 5. DEPENDANT INFORMATION See Annexure 5.1 for dependant classification and the proof that is required in each instance. Spouse/Partner Relationship to applicant (e.g. wife) Dependant 1 Relationship to applicant (e.g. son) Dependant 2 Relationship to applicant (e.g. son) Dependant 3 Relationship to applicant (e.g. son) 2

3 ANNEXURE 5.1: DEPENDANT CLASSIFICATION (PLEASE REMEMBER TO INDICATE IF DOCUMENTS ARE ATTACHED) DEPENDANT DEFINITION Adopted child DOCUMENTS REQUIRED Court order and ID or birth certificate (if over 21 and a full or part-time student, provide proof of registration at an accredited institution, plus an affidavit stating financial dependency on main member [part-time students only]) DOCUMENTS ATTACHED Common-law partner Affidavit and ID Customary spouse Affidavit and ID Foster child Court order and ID or birth certificate (if over 21 and a full or part-time student, provide proof of registration at an accredited institution, plus an affidavit stating financial dependency on main member [part-time students only]) Parents of member Affidavit and ID Same-sex partner Affidavit and ID Sibling Affidavit and ID Spouse Marriage certificate and ID Stepchild Grandchild Natural child Affidavit/Marriage certificate and ID or birth certificate (if over 21 and a full or parttime student, provide proof of registration at an accredited institution, plus an affidavit stating financial dependency on main member [part-time students only]) Affidavit and ID (parent of grandchild should be a registered dependant of the principal member) ID or birth certificate (if over 21 and a full or part-time student, provide proof of registration at an accredited institution, plus an affidavit stating financial dependency on main member [part-time students only]) 6. PREVIOUS MEDICAL FUND MEMBERSHIP HISTORY (PLEASE ATTACH MEMBERSHIP CERTIFICATE OF PREVIOUS MEDICAL FUND) Are or were you or any of your nominated dependants previously beneficiaries of a registered medical fund? No If yes, a certificate of membership indicating your date of resignation from that fund must be attached before registration on the Transmed Medical Fund will be finalised. Please note that in terms of the Medical Schemes Act, it is unlawful to be registered on two funds simultaneously. List each medical fund that you have been a member of (note that only medical funds registered in South Africa apply). This information needs to be supplied for the principal member and all dependants applying for membership. If more space is required, please include additional pages. Name of member Name of fund Membership number Date joined Date ended 7. MEDICAL HISTORY AND GENERAL HEALTH QUESTIONS THIS SECTION IS ONLY APPLICABLE TO MEMBERS JOINING AFTER THREE MONTHS OF EMPLOYMENT MEDICAL HISTORY AND GENERAL HEALTH QUESTIONS Please provide the required information by ticking the relevant boxes below. If the answer to any question is yes, please provide details in section 8. I understand that if I do not provide full details of all the medical conditions known to me at the time of this application or before acceptance of this application, my membership will be declared null and void. 1. Are you or any of your dependants currently pregnant? No If so, for how many months have you/she been pregnant? Number of months Name and surname of mother-to-be 2. Have you or any of your dependants ever had any of the following? 2.1 Any condition of the heart (e.g. heart attack, rheumatic fever, heart murmur, coronary artery disease, chest pain, shortness of breath or palpitations)? No 2.2 High blood pressure or diseases of the blood vessels (e.g. raised cholesterol, stroke or circulatory disorder)? No 2.3 Any respiratory or lung ailments (e.g. asthma, bronchitis, persistent cough or tuberculosis)? No 3

4 2.4 Any condition of the digestive system, gall bladder or liver (e.g. actual or suspected gastric No or duodenal ulcer, recurrent indigestion, hiatus hernia, hepatitis B or persistent diarrhoea)? 2.5 Any disease or condition of the kidneys, bladder or reproductive organs (e.g. albumin in urine, No stones, prostatitis, pancreatitis or venereal disease) or gynaecology-related symptoms or conditions (i.e. problems with female organs)? 2.6 Any nervous or mental complaint (e.g. epilepsy, migraine, blackouts, loss of consciousness, No paralysis, anxiety state or depression)? 2.7 Any ear, eye, nose or throat condition (e.g. ear discharge, defective vision, recurrent tonsillitis, No swollen glands, persistent mouth sores, cataracts or any hereditary eye disease, functional nose impairment or chronic sinusitis)? 2.8 Any condition or disease of the muscles, bones, joints, limbs, spine (e.g. rheumatism, arthritis, gout, slipped disc or other back trouble)? No 2.9 Diabetes, sugar in blood or urine, thyroid or other glandular or blood disorder? No 2.10 Any lumps, growths (benign or malignant), types of cancers (including Hodgkin s disease and leukaemia), No skin cancer or skin disorders? 2.11 Any tropical disease (e.g. bilharzia, malaria or cholera)? No 2.12 Any other condition, illness, disease, disorder, disability or accident that required medical, radiological, No surgical, pathological or dental investigation during the past twelve months? 2.13 Been tested for or received or expect to receive any medical advice, counselling, treatment or blood test No in connection with HIV/AIDS or any AIDS-related condition or any sexually transmitted disease (e.g. hepatitis B, gonorrhoea or syphilis)? 3. Have or are you or your dependants receiving surgical, medical, major dental (implants), chiropractic, No optical or gynaecological treatment, procedures, advice or tests? 4. Do you or any of your dependants have any physical (including dental) abnormality, deformity, handicap No or defect, whether congenital or as a result of an accident, disease or some other cause? 5. Do you or any of your dependants currently use medication on a daily basis? No 6. Do you or any of your dependants suffer from any other ailment or disease at present? No 7. Are there, in respect of you or your dependants, any other circumstances not mentioned elsewhere in this declaration/questionnaire relating to past or present diseases, accidents, operations or other conditions, including pregnancy, for which advice has been sought or treatment has been received or recommended during the past five years? No 8. Are you or any of your dependants expecting to undergo any procedure, operation, confinement or No receive any major dental treatment during the next twelve months? If you require additional space, please complete a separate sheet of paper and attach it to the application. Please attach the relevant medical reports. Should you be HIV positive and do not wish to disclose this on your application form, please note that once you have received your membership number, you must fax confirmation of your HIV/AIDS status to the HIV YourLife programme on or it to mail@hivyourlife.co.za to ensure registration on the programme. 8. ADDITIONAL MEDICAL INFORMATION PLEASE PROVIDE DETAILS BELOW IF YOU ANSWERED YES TO ANY OF THE UNDERWRITING QUESTIONS. IF MORE SPACE IS REQUIRED, PLEASE INCLUDE ADDITIONAL PAGES. Question number Name of patient Illness or condition Date and duration of illness Name of doctor, hospital or institution Treatment recommended: Likely date and duration of treatment Failure to disclose any pre-existing conditions could result in limited benefits or the exclusion of benefits or the termination of your membership. 4

5 9. YOUR PREFERRED METHOD OF RECEIVING WRITTEN COMMUNICATION Please indicate your preferred method of receiving communication. Please choose only one method of delivery for each item. Personalised letters Post Claims statements* Post Cell phone Claims processed Post Cell phone *You need a cell phone that can access the Internet to receive your statements via SMS. 10. TERMS AND CONDITIONS Please read the clauses below carefully. They contain an acknowledgement of fact/a potential liability to pay costs/an indemnity provision and they may potentially compromise your rights. Please ensure that you fully understand the consequences of the clauses. 1. The answers that I have given here are full, complete and true. I understand that if I am accepted as a member of the Fund, my answers on this form will form the basis of my membership. 2. I apply for my dependants and I to join Transmed Medical Fund. 3. I have been provided with a summary of the rules of the Fund (i.e. benefits guide) and I have been given an opportunity to consider, familiarise myself with and agree to be bound by the rules if my application for membership is accepted. I understand that I may obtain a full copy of the rules in accordance with the Medical Schemes Act. The rules of the Fund are also available on the Fund s website at I understand that the summary of the rules of the Fund will be amended by the Fund annually. 3.2 I also understand that, in the event of a dispute, the rules will prevail. 3.3 The words used in this application have the meaning that the rules give them. 4. I acknowledge that if my dependants and I do not disclose all the information that is relevant to the assessment of this application, it will make any contract that may result from this application null and void. 4.1 If I or my dependants have failed to disclose relevant information and the contract then becomes void, the Fund will have the right to claim back any amounts that it may have paid to me or any person on behalf of me or my dependants under such contract. 4.2 I will be reimbursed any membership payments made by me, but may be charged a reasonable penalty by the Fund. 5. I will notify the Fund if any alteration takes place in any circumstances on which the Fund based its assessment of its risk after the date of this application and before the date of the Fund s acceptance of the risk. I acknowledge that failure to do so will make any contract that may result from this application null and void. 5.1 If I or my dependants have failed to disclose relevant changes in circumstances and the contract becomes void, the Fund will have the right to claim back any amounts that it may have paid to me or any person on behalf of me or my dependants under such contract. 5.2 I will be reimbursed any membership payments made by me, but may be charged a reasonable penalty by the Fund. 6. I have been provided with a schedule reflecting the benefits I may become entitled to if this application is accepted. The benefits have also been explained to me and I have had an opportunity to question and consider them. 6.1 The monthly contributions I will be expected to pay if this application is accepted have been explained to me. I have had an opportunity to question and consider the monthly contributions and I understand the consequences if I fail to pay the monthly contributions. 6.2 It is my responsibility alone (as a member) to make sure that the Fund receives the monthly contribution. 6.3 I will pay all sums that I owe to the Fund on demand. Failure to pay any debt due to the Fund may result in the suspension of my membership and/or having the matter handed over to a third party for debt collection. 6.4 Should we not receive a single month s contribution, it will result in the suspension of the Fund s benefits. 6.5 Should we not receive two months contributions, it will result in the cancellation of my membership of the Fund If the employer is responsible for paying my contributions, I authorise and instruct my employer to: deduct from my remuneration (and any other sums due to me) any amounts that I may owe to the Fund from time to time pay such amounts to the Fund. 7.2 I also authorise and instruct any person (such as my employer or a pension or provident fund) who holds funds on my behalf after I cease employment, to pay and continue to pay the amounts referred to in clause 7.1 to the Fund as and when it is due. 8. If I am accepted as a member, I must, both now and in future, give the Fund all such information and evidence as it may require from time to time. 8.1 For this purpose, I authorise the Fund and/or its agents to obtain from any person any necessary information that they may require concerning any of my dependants or me in assessing any risk or claim in relation to this application or regarding my medical Fund membership. I direct that person to provide the Fund and/or its agents with such information on request. 8.2 I authorise any medical doctor or other provider who has attended me in the past or who will attend me in the future, to provide the Fund and/or its agents with such information as it may require. 8.3 I therefore give up the protection afforded to me under the provisions of any law or regulation that restricts the giving of such information and expressly authorise the Fund to access my information, as and when it is necessary. 9. I understand that this is an indemnity. This means that in certain circumstances I will be responsible for paying for claims or damage incurred by the Fund and/or its agents on request. 9.1 I will obtain the necessary consent from any of my dependants (who may become members in terms of this application) that may be required. 9.2 If I do not obtain their consent, I will have no claim against the Fund and/or its agents. 9.3 If I do not obtain their consent and if any third party has a claim against the Fund and/or its agents because my dependants did not consent, as required, I will be responsible for any costs, fees or other amounts the Fund and/or its agents may be liable for. 5

6 10. I consent to the recording of all conversations between me and the Fund and/or its agents and all information obtained through these conversations will form part of the records of the Fund and/or its agents. I also consent to all these records remaining the sole property of the Fund and/or its agents. 11. I will notify the Fund should I or any of my dependants require hospitalisation for a planned event at least 48 hours before the event. I acknowledge that failure to do so will result in a reduction of benefits the Fund will pay to me or any supplier on my or my dependant s behalf for any procedure undertaken. 12. I understand that this application form is valid for 30 days only. 13. I am aware that the Fund may ask for proof of identification during any stage of communication with the Fund. 14. In the case of new members of the Fund, the following may apply: 14.1 a three-month general waiting period 14.2 a twelve-month exclusion on a pre-existing condition 14.3 a late joiner contribution penalty. 15. I undertake to give a calendar months notice should I wish to terminate my membership. 16. Please note: Registration will be delayed should this application be incomplete or if the required documents are not attached. Should your application reach our offices after the fifth day of the month, you will be registered from the first day of the following month. I HAVE READ AND UNDERSTOOD THE AFOREMENTIONED CLAUSES, HAD AN OPPORTUNITY TO QUESTION AND CONSIDER THEM, AND I AGREE TO THE CONSEQUENCES OF THEM. 11 HUMAN RESOURCES SECTION MEMBER NAME MEMBER SIGNATURE DATE OFFICIAL EMPLOYER STAMP SIGNATURE OF HUMAN RESOURCES OFFICER DATE CHECKLIST PLEASE INDICATE BELOW THAT THE APPLICATION FORM HAS BEEN COMPLETED IN FULL AND THAT THE REQUIRED DOCUMENTS ARE ATTACHED. SECTION DESCRIPTION TICK BOX All sections All sections of the application form filled completely Section 1: Copy of ID Copy of member ID attached Section 3: Bank details for direct deposits or refunds The member s full bank details have been completed Section 4: Options Did the member choose one option only? Annexure 6.1: Dependant classification All required documents/proof attached Section 7: Medical fund history Membership certificate of previous medical fund cover attached Declarations/Signatures Are declarations and signatures signed? 6