PLEASE USE BLACK INK TO COMPLETE ALL SECTIONS AND RETURN AS SOON AS POSSIBLE TO ENSURE SPEEDY REGISTRATION

Transcription

1 2016 APPLICATION FOR MEMBERSHIP t(f!~~ PLEASE USE BLACK INK TO COMPLETE ALL SECTIONS AND RETURN AS SOON AS POSSIBLE TO ENSURE SPEEDY REGISTRATION. Please indicate our option choice b ticking the appropriate box: MEDICAL FUND OPTIONS D Primar Care D Savings Care D Affordable Care D Full Benefit FOR INTERNAL USE ONLY Medical aid number: Emploer code: ~~-~~-~~-~~~ SECTION 1 PERSONAL DETAILS OF PRINCIPAL MEMBER Title: Surname: First names: Initials: ID number: Postal address: Code: Phsical address: Code: address: Occupation: Telephone (H): ( <V): ( (C) ~ SECTION 2 EMPLOYER DETAILS Date joining the Fund: Date of benefit: Income categor: Paroll number: Member's share of contribution: Emploer's share of contribution: Emploer or Account number: NB: Proof of income/salar slip to be submitted with this form. We confirm that the applicant is emploed and commenced emploment on (date): and that contributions are being deducted in accordance with the applicant's income and the eligible dependants, in terms of the appropriate contribution table. An further changes to the emploee's status will be advised to the Fund within seven das. Compan/division: Name: Designation: contact: Date: Telephone: Fax: SIGNATURE OF EMPLOYER OFFICIAL STAMP OF EMPLOYER

2 SECTION 3 PRINCIPAL MEMBER & DEPENDANT DETAILS (SHADEDAREASFOROFFICEUSEONLY) Marital codes Gender codes Relationship codes M =Married S =Single M =Male S = Spouse C = Child D =Divorced W=Widowed F =Female P = Parent LP = Life partner Important: New applications will not be considered unless the correct documentation is supplied. n-compliance will result in either a dela in processing or rejection of our application. (Please complete names as stated in our identit document or birth certificate.) NB: Shaded areas for office use onl Surname First name Date of birth Gender Marital status Relation ship ID number Principal member 00. Mr N/A Waiting period / From Condition-specific waiting period Dep. code 01 / From /VV If there is a difference between the surname of an child dependant and the principal member, please state reason: Waiting period / From Condition-specific waiting period / From Dep. code 02 /VV If there is a difference between the surname of an child dependant and the principal member, please state reason: Waiting period / From Condition-specific waiting period / From Dep. code 03 If there is a difference between the surname of an child dependant and the principal member, please state reason: Waiting period / From Condition-specific waiting period / From Dep. code 04 If there is a difference between the surname of an child dependant and the principal member, please state reason: Waiting period / From Condition-specific waiting period / From te: Child Dependants who are aged between 21 and 25, who are either full-time students or financiall dependent on their parents, must provide proof thereof. (Full-time students, please submit a confirmation letter from our registered institution; financiall dependent chi a Clepemfan.ts lease submit an affidavit).

3 SECTION 4 PREVIOUS MEDICAL SCHEME Please give full details of our membership of an previous medical scheme(s) and termination dates (list the most recent first and provide proof b attaching our certificate/s of membership). Name of scheme: Membership number: ~~-~-~~-~-~~-~-~~-~-~~ Membership from: to Are ou still a member: DYes D Name of scheme Membership number: ~ ~~-~-~~-~-~~-~-~~-~-~~ Membership from: to Are ou still a member: DYes D Did ou contribute to a savings account? DYes D If es, please indicate what percentage ou paid towards savings: % Waiting period imposed? DYes D If es, please indicate what waiting periods were imposed: Late joiner penalties imposed? DYes D If es, please indicate what penalties were imposed: SECTION 5 FOR INTERNAL USE ONLY Current age Less: creditable coverage = Number of not covered Less: qualifing age Years subject to penalt Number of Penalt imposed subject to penalt (please tick) 1-4 5% % % % Vettedb(name): Signature (supervisor): Date: Processedb(name): Signature: Date: SECTION 6 MEDICAL HISTORY: PRINCIPAL MEMBER & DEPENDANTS TO BE REGISTERED To match the correct dependant code with the codes below, please refer to Section 3. IMPORTANT: Please submit proof and date of treatment of pre-existing health conditions of principal member and all dependants.this means a sickness or condition for which medical advice, diagnosis, care or treatment was recommended or received during the 12 months preceding application. Please ask our treating doctor to help ou to provide the relevant ICD-10 code for our condition. Please provide full details for an of the conditions below in the space provided and attach relevant medical reports to this form: Dependant number Mark (Mark with X where ICD- I 0 Date of last one applicable) code treatment An disorder of the heart (eg, rheumatic fever, heart murmur, Y N 00 0 I coronar arter disease, chest pain, shortness of breath or palpitations)? 2 Y N 00 0 I circulator disorder (eg, cramp during exercise, stroke, high cholesterol, hardening of arteries)?

4 SECTION 6 MEDICAL HISTORY {CONTINUED) 3 An respirator or lung disease (eg, asthma, bronchitis, N persistent cough, tuberculosis? 4 An disorder of the digestive sstem, gall bladder, pancreas or liver (eg, actual or suspected gastric or duodenal ulcer, recurrent indigestion, hiatus hernia, anal bleeding, haemorrhoids or jaundice)? 5 Disease or disorder of the kidnes, bladder or reproductive N organs (eg, albumin in urine, kidne stones, prostatitis, N venereal diseases, infertilit or impotence)? 6 An nervous or mental complaint (eg, epileps, blackouts, anxiet or depression)? 7 An tpe of nerve ailment (eg, loss of sensation, numbness or paralsis)? 8 Ear, ee, nose or throat disorder (eg, discharge, defective vision)? 9 Disorder or disease of skin, muscles, bones, joints, limbs, N N N spine (eg, psoriasis, arthritis, gout, slipped disc or other back N trouble)? 10 Diabetes, hormonal imbalance, glandular or metabolic diseases, throid or blood disorders? N Cancer, growth, tumour of an kind? N An other illness, disorder, operation, disabilit or accident (eg, fractured nose, breathing disorers, mammar hpertroph [enlarged breasts with associated side-effects),aids, N congenital abnormalities, etc)? 13 Are ou pregnant? State expected date of confinement. N Are ou or our dependants currentl undergoing or IS expecting to undergo an medical, dental or surgical N treatment? Have ou or our dependants received an medical, dental or surgical treatment? 16 Have an exclusions been imposed on ourself or our N dependants b an medical scheme on which ou have been N registered? If, please state details below. 17 Please give an other relevant information: DISCLAIMER: I will inform the Fund of an changes in m health status or the health of m dependantfs within 30 das of the change occuring from the date of application and within 90 das of the activation date.

5 SECTION 7 GENERAL I hereb appl to be admitted as a member of Sizwe Medical Fund, hereafter referred to as "the Fund" and agree to familiarise mself with, and abide b, its rules and regulations as amended from time to time. I am familiar with the benefits and conditions of m chosen option and hereb authorise m emploer to deduct from m salar m monthl contribution as I ma lawfull owe to the Fund and to remit such amounts to the Fund. Furthermore, I understand that I will be held liable for an legal costs incurred in the recover of an amounts owing to the Fund. I hereb authorise an doctor or other person, who ma be in possession of, or hereafter acquire information concerning m health or the health of an of m dependants, to disclose this information at their reasonable discretion. I understand that the Fund ma request a medical report at its own cost when I join the Fund and that all health and personal information given to the Fund be handled confidentiall b them for purposes outlined in Section I 0. In the event the Fund wishes to use m, or m dependants', confidential information for purposes other than those outlined in Section I 0, the Fund will require consent from me or m dependants. I understand that the Fund ma impose a general and/or condition-specific waiting period according to the Medical Schemes Act ( 131 of 1998) when I and/or m dependants join. I understand that according to the Medical Schemes Act, I ma onl belong to one medical scheme at a time. I consent to all conversations between the Fund or its contracted parties and mself being recorded. I understand that application for admission to the Fund is not subject to the services of a broker, but should I appoint the below broker to manage m application, I am entitled to cancel the broker's services at an time. I hereb declare that the information in this application is true and correct and agree that an false declaration could render m application null and void. I hereb declare that the accurac and completeness of all answers, statements and other information provided b or on behalf of me, is m responsibilit. Applicant's signature: IMPORTANT: Failure to disclose all relevant and/or correct information ma adversel affect the benefits available to ou and our dependants. SECTION 8 APPOINTED BROKER DETAILS (WHERE APPLICABLE) I authorise (broker's name) to act and sign all necessar documentation on m behalf and that his/her commission will be paid on receipt of m first contribution to the Fund. To be completed b broker: Brokerage: Financial Services Provider number Intermediar code: Tel: ( Cell: Date: Phsical address: Postal code: Postal address: Postal code: CMS accreditation number: I hereb declare that I am accredited with the Council of Medical Schemes, am a licensed Financial Services Provider and have a valid contract with Sizwe Medical Fund. I hereb declare that the information on this application form is correct and that there is no material misrepresentation of an fact. In the event of material misrepresentation or unlawful conduct, I undertake to refund all monies paid in consequence of such misrepresentation. The applicant is familiar with the information requested in the application form and all the relevant information was provided to the applicant. The advice given to the member was impartial and in the best interests of the applicant. Applicant's signature: Broker's signature: FOR OFFICE USE ONLY Commission paable: SECTION 9 THE FUND RESERVES THE RIGHT TO CANCEL The fund reserves the right to cancel or suspend membership and impose restrictions on a member or dependants, on the grounds of: A) FAILURETOTIMEOUSLY PAYTHE MONTHLY CONTRIBUTIONS AS SPECIFIED INTHE RULES B) FAILURETO REPAY ANY DEBTTOTHE FUND C) SUBMISSION OF FRAUDULENT CLAIMS D) THE N-DISCLOSURE OP-MAl=~RIAL INFORMATION

6 SECTION 10 FUND DECLARATION Sizwe Medical Fund declares that the member's personal details and medical information, obtained from healthcare providers with the consent of the member, shall be kept confidential and will not be used for purposes of related compan business nor sold for commercial purposes. All staff within the Fund and contracted third parties are bound b internal confidentialit agreements. Information given to the Fund will be used for the following purposes: processing the member's application, re-imbursement of claims, determining member entitlements to benefits, managed care and risk management practices. In the event of a breach in confidentialit, the Fund assumes responsibilit and the breach will be managed according to the Fund's internal protocols. SECTION 11 INCOME DECLARATION AND BANKING DETAILS FOR REFUND PURPOSES AND DEBIT ORDER AUTHORITY A) Banking details Bank: Branch: Branch code: Tpe of account: ~Accountnumber: EFT pament (pament of claims refunds directl into our bank account): Please include an original cancelled cheque (for a cheque account) or a recent original bank statement (for a savings or transmission account). Copies of cheques or bank statements cannot be accepted. B) Income declaration (compulsor for all members) I hereb declare that m monthl income is R per month. (Substantiating proof of income must be attached and must be resubmitted to the Fund on an annual basis.) C) Contribution paments I hereb authorise that the monthl contribution, as raised b the Sizwe Medical Fund, ma be withdrawn from the above-mentioned account on the I st of each month for the current month's membership contributions. This pament will represent the full monthl contribution paable to the Fund. I further understand that if pament is not made to the Fund on the I st of each month, then m membership can be terminated with immediate effect and all benefits derived from the Fund will cease. I hereb declare that the information in this application is true and correct and agree that an false declaration could render m application null and void. Date of first pament: I I SECTION 12 ESSENTIAL DOCUMENTS (COMPULSORY) Please provide the following documentation with our application Cop of ID for ourself and our dependants Birth certificates of children (where ID is not available) Clinic cards for newborn babies (within 30 das of birth to avoid waiting periods) Documentar proof in the case of adopted/foster children Marriage certificate when registering a spouse (within 30 das of marriage to avoid waiting periods) Affidavit when registering a common law spouse or partner confirming co-habitation (where applicable) Membership certificates with termination dates from previous medical aids, for member and dependants (where applicable) Proof of stud for dependant/s from the age of 21, or affidavit for financiall dependent dependant/s, or doctor's letter for mentall or phsicall disabled children Proof of taxable income (ie, pa slip, SARS ITA 34 form, etc) Either an original cancelled cheque (for a cheque account) or an original bank statement (for a transmission or savings account) so that claims can be paid directl into our bank account. PLEASE ENSURE THIS SECTION IS COMPLETED IN.. FULL AND ALL NECESSARY DOCUMENTS ARE ATTACHED WITH YOUR APPLICATION. FAILURE TO SUBMIT THE RELEVANT DOCUMENTS WILL DELAY THE PROCESSING OF YOUR MEMBERSHIP APPLICATION. :. I I I II If ou have an queries, please call Customer Eare on 0860 I or visit