CHECKLIST FOR CAMAF APPLICATION FORM

Transcription

1 CHECKLIST FOR CAMAF APPLICATION FORM I.D document (s) or birth certificate (s) for the main member and dependant (s) Motivational form (if applicable) General health certificate (if older than 55 years old or on request) Letter from institution where children are registered to study Proof of guardianship in case of legal dependancy Proof of income if selecting CA - First Choice or Network Choice Copy of marriage certificate (if applicable) Proof of banking details Certificate of membership from previous medical aid/s Domestic Partnership form (if necessary) FOR CAMAF USE ONLY Member No. Group No. Date Admitted (ddmmyyyy) Special Conditions Loaded by: Checked by: Registered For and on behalf of the board: PLEASE NOTE: This application form cannot be finalised without the supporting documentation

2 APPLICATION FORM Please tick ( ) applicable box Please complete all relevant sections of this form in BLOCK CAPITALS throughout. Specify your choices by ticking relevant boxes Eternity Private Health Fund Administrators (PTY) LTD, Wedgefield Office Park, 17 Muswell Road South, Bryanston, 2021 PO Box 2964, Randburg, 2125, South Africa Tel: or (+2711) , Customer Services or custserv@camaf.co.za Pre-authorisation or preauth@eternityhealth.com Website: 1. PERSONAL AND ADDRESS DETAILS - COPY OF ID DOCUMENT TO BE ATTACHED Title Mr Mrs Dr Prof Rev Other (specify) Surname Initial(s) Full Name(s) Preferred Name Gender (M = Male ; F = Female) RSA Identity No. Marital Status Single Married ANC Married COP Divorced Widowed Other If Married, indicate: Date (ddmmyyyy) Place of marriage Home No. Cell No. Work No. Fax No. Address Postal Address *Please note: All correspondence will be sent via , unless otherwise requested. Domicilium Address (Physical Address) Please select preferred method of communication: Post Postal Postal I would like to receive sms confirmations: Yes No 2. DEPENDANTS YOU WISH TO REGISTER* - COPY OF ID DOCUMENT TO BE ATTACHED FIRST NAMES (State where surname different) KNOWN AS DATE OF BIRTH AGE SEX RELATIONSHIP ID NUMBER DATE TO ADMIT

3 3. EMPLOYMENT DETAILS - MUST BE SIGNED BY THE REPRESENTATIVE OR EMPLOYER Has your application for membership been necessitated by a change in employment? Yes No If yes, please state details: Name of previous employer: Contact person and number of previous employer: Date of resignation: (ddmmyyyy) Current Employment Status Employed Self Employed Retired Income Type Salary Commission Income from Investments Name of Current Employer Current Employer Address (Physical) (Postal) Department Branch Current Position Length of Employment Highest Qualification Date on which the Applicant commenced Permanent Employment at the current Employer (ddmmyyyy) Date on which the Applicant is eligible and would like to join CAMAF COMPANY STAMP (ddmmyyyy) Should the above two dates differ, please give reasons: Group Number Employee Number Date Position of Employer Representative Signature of Employer Representative Progressive Benefit Options: 1. CA - Vital 2. CA - Double Plus 3. CA - Alliance Additional Benefit Options: 1. CA - First Choice 2. Network Choice 4. BENEFIT OPTION CHOICE First Choice Network Choice R 0 - R R R R R R R R R 0 - R R (Please tick the appropriate box) Proof of income in the form of payslip or letter of appointment Please tick this section to indicate your salary band. If you do not complete the section your contribution will default to that of the highest income category. Please submit proof of your income in the form of an IRP5 form, tax certificate or a copy of your pay slip.

4 5. BANKING DETAILS - REQUIRED TO PAY REFUNDS DIRECTLY INTO YOUR BANK ACCOUNT No banking details will be loaded without proof. Name of Bank Branch Name Branch Account No. Type of Account Cheque Savings Transmission Note: If these details are not correct, the Fund will not be able to settle your claims. No credit card details will be accepted. This is a condition of membership stipulated in our rules. It should be noted that this is not a debit order mandate. Please Attach: Original cancelled cheque Copy of statement Letter from bank with details of account. PLEASE NOTE: ABSA HAS A STANDARD BRANCH CODE (632005) 6. PREVIOUS MEDICAL DETAILS CERTIFICATE OF MEMBERSHIP OF PREVIOUS MEDICAL AID, COVERING THE LAST 24 MONTHS, MUST BE ATTACHED Have you or your dependant(s) been a member/dependant of another registered medical scheme in the past? Yes No Name of medical scheme Member s name From To Membership No. Have you been a member or a dependant of CAMAF previously? If yes, please state: Membership No. Yes No Status (P=Principal Member, D=Dependant) Period(s) from? (ddmmyyyy) to (ddmmyyyy) NOTE: Waiting periods may be imposed, unless a certificate of membership is attached proving transferability. 7. QUALITY OF LIFE MANAGEMENT MEDICAL QUESTIONNAIRE SHOULD YOU WISH TO KEEP THE INFORMATION INCLUDED IN THIS QUESTIONNAIRE CONFIDENTIAL, PLEASE INSERT SECTION 7 IN A SEALED ENVELOPE AND RETURN IT WITH THE APPLICATION FORM. YOUR EMPLOYER MUST THEN SIGN SECTION 3 AND RETURN THE ENVELOPE AND FORM TO US. IT IS VERY IMPORTANT TO NOTE THAT YOUR APPLICATION WILL NOT BE PROCESSED UNLESS WE RECEIVE THIS QUESTIONNAIRE TOGETHER WITH THE APPLICATION FORM PLEASE COMPLETE THE DETAILS BELOW TO ENSURE THAT SECTION 7 CORRESPONDS TO YOUR APPLICATION FORM PLEASE COMPLETE ALL SECTIONS N.B. All the questions below must be answered with a YES or NO. If YES, full details must be given in the appropriate spaces. If the space provided is not sufficient please write on a separate sheet of paper and attach it to this form. QUESTIONS MARK WITH AN X YES NO NAME OF PATIENT ILLNESS OR CONDITION DATE DURATION EXTENT OF ILLNESS AND NATURE OF TREATMENT RECEIVED MEDICAL / SURGICAL HISTORY 1. Any Cardiac Conditions e.g. Angina, High Blood Pressure, Cardiac Failure, Palpitations, Bypass, Arrythmias, Heart Valve Disease, Heart Murmurs, etc.

5 QUESTIONS 2. Any Cancer/Malignancies/Tumours (Please Specify) 3. Any Disorder of Central Nervous System e.g. Epilepsy, Migraine, Parkinson s Disease, Paralysis, Multiple Sclerosis, Stroke, Alzheimer s Disease, etc. 4. Any Disorder of Circulatory System/ Blood Disorders e.g. Deep Vein Thrombosis, Anaemia, Lipid Problems, High Cholesterol, etc. 5. Any Cosmetic Treatment e.g. Breasts/Facial Surgery, Bat Ears 6. Any Disorder of Digestive System/ Liver Disorders e.g. Ulcers, Heartburn, Hernias, Hepatitis, Crohn s Disease, Ulcerative Colitis, Gallbladder, etc. 7. Any Disease of Ear, Nose, Throat, Eyes & Teeth e.g. Sinus, Tonsillitis, Deafness, Defective Vision, Glaucoma, Cataract, Gum/Tooth Disorder, Allergies etc. 8. Any Disorders of the Endocrine System e.g. Diabetes, Thyroid Disorder, Addison s Disease, Sugar in Urine etc. 9. Women s Health e.g. Ovarian Cyst, Endometriosis, Infertility, Hysterectomy, Hormone Replacement Therapy, Breast Lumps, Menstrual Disorders etc. 10. Any Disorder of the Immune System e.g. HIV/AIDS, Any Immunological Disorder etc. 11. Any Injuries/Disabilities e.g. Motor Vehicle Accident, Workmans Compensation (Please Specify Date of Injury) 12. Any Mental Disorder e.g. Depression (Please Specify Type), Anxiety/Panic Attack,Schizophrenia, Drug & Alcohol Abuse, Psychotherapy etc. 13. Any Disorder of the Musculo Skeletal System e.g. Arthritis, Fractures, Spinal/Hip/Knee Condition, Plegia, Gout, Osteoporosis, Muscular Dystrophy etc. 14. Any Disorder of the Respiratory System /Lung Conditions e.g. Asthma, Chronic Bronchitis, Emphysema etc. 15. Any Disorder of the Skin e.g. Eczema, Growths, Acne, Keloids Psoriasis, Allergies etc. 16. Any Urology Disorder e.g. Prostate Disorder, Prolapse Bladder, Infections, Protein, Albumin in Urine etc. 17. Any Infectious/Tropical Disease e.g. Bilharzia, Malaria, T.B. etc. 18. Any Family History of Any Condition or Surgery? 7. QUALITY OF LIFE MANAGEMENT (continued) 19. Are you currently on any medication? If yes, please specify. Please refer to the attached AAL communication regarding chronic medicine application. 20. Has any application for medical aid, for you, or your dependants been accepted on special terms, declined, deferred or withdrawn? 21. Any previous operations, treatment, investigations & tests not mentioned above? 22. Any future operations, treatment, investigations & tests not mentioned above? MARK WITH AN X YES NO NAME OF PATIENT ILLNESS OR CONDITION DATE DURATION EXTENT OF ILLNESS AND NATURE OF TREATMENT RECEIVED

6 QUESTIONS CONDITION/OPERATION 23. Pregnancy Please indicate the Expected date of delivery if pregnant 7. QUALITY OF LIFE MANAGEMENT (continued) MARK WITH AN X YES NO NAME OF PATIENT ILLNESS OR CONDITION DATE DURATION EXTENT OF ILLNESS AND NATURE OF TREATMENT RECEIVED 8. DECLARATION TO BE COMPLETED BY MEMBER THIS APPLICATION FORM WILL NOT BE VALID UNLESS EVERY QUESTION HAS BEEN ANSWERED AND THE MEDICAL HISTORY HAS BEEN COMPLETED AND INSERTED. 1. I hereby apply for admission to membership of the Chartered Accountants (S.A.) Medical aid Fund in terms of the rules of the Fund. 2. I acknowledge and agree that: 2.1 I have familiarised myself with the benefits covered by my package of choice and understand that I may only change my benefits at the beginning of each calendar year unless there are exceptional circumstances; 2.2 if my application for membership is accepted, my membership of the Fund shall be subject to and in terms of the rules of the Fund, as amended from time to time; 2.3 if the principal member or the dependants do not have transferability according to the rules of the Fund, the Fund may impose waiting periods on such dependants in terms of the Medical Schemes Act 31 of 1998 and the Regulations under this act; 2.4 the member firm as a collection agent may collect contributions on my behalf but I will ultimately remain liable for any outstanding amounts. 2.5 I have read the applicable CAMAF brochure in detail and I fully understand the health care cover offered on my chosen benefit option. 3. I warrant that all information given in this application is true and correct. 4. I hereby agree that: 4.1 all statements in this application form shall be the basis of my proposed membership and that any misstatement in or omission from this form may lead to refusal to admit any claims for treatment given to me, or to my membership being declared null and void ab initio; 4.2 upon termination of membership of the Fund a month s written notice from the member firm s representative if applicable is required. 5. I hereby authorise the Fund: 5.1 to obtain any additional information it may require to enable it to consider my application for membership; and 5.2 during my period of membership to obtain any information it may require concerning my medical history. 6. I hereby warrant that I have (If applicable) disclosed my total household monthly income and understand that this must be updated annually. 7. Anything omitted on my medical history may result in investigations. These investigations may lead to subsequent waiting periods being imposed or may result in the membership being declared null & void). 8. The Scheme reserves the right to share medical information with treating providers (ddmmyyyy) Signature of Member PLEASE ENSURE THAT SECTION 7 IN RESPECT OF THE QUALITY OF LIFE OF THE PROSPECTIVE MEMBER AND HIS/HER DEPENDANT(S) IS INSERTED IN THE APPLICATION FORM