my medihelp application form 2017

Transcription

1 September /18 Page 1 m medihelp application form 2017 Enquiries: Fax: newbusiness@medihelp.co.za Postal address: PO Box 26004, ARCADIA, 0007 For office use onl Membership number M H How to complete this form: 1. Please complete in print, using black ink, and , fax or post the form to Medihelp. 2. Please complete all sections in full and sign the application form. te the following at section 5: 2.1 If ou appl for membership of the Necesse benefit option, complete item Never sign a blank application form. 1. date from when membership is required m m details of (person who requests membership) ID/passport number Title Mr Mrs Ms Other (specif) A cop of our passport must be attached if ou use our passport number. Initials First names Gender Male Female Marital status Married in communit of propert Married out of communit of propert Single Divorced Widow Widower Other (specif) m m d d Date of marriage Income tax number Language Afrikaans English 3. contact details of Postal address Tel: (W) Code. Residential address Tel: (H) Code. Code Fax: Code. Code Ma Medihelp use our/our dependants personal details to determine the qualit of our service? To improve the qualit of our communication to ou, please indicate if the following is applicable to ou: Visuall impaired Hearing impaired 4. details of emploer / institution responsible for our subscription paments NB: Complete onl if subscriptions are paid in full or partiall b our emploer or an other institution. Name of emploer Contact person responsible for the account Tel: Code. Title Mr Mrs Ms Other (specif) Initials Contact person s address Emploer s postal address Code Branch code/emploer group. Office stamp of emploer Paroll number Appointment date Appointment Pa area Permanent Temporar

2 /18 Page 2 5. choice of benefit option (choose onl one benefit option b marking with an X at 5.1) 5.1 benefit options te: If ou choose an of the network options, ou ma use onl hospitals in the specific network for planned hospital admissions. Dimension Prime 1 Dimension Prime 1 (Network) Dimension Prime 2 Dimension Prime 2 (Network) Dimension Prime 3 Dimension Prime 3 (Network) Dimension Elite Medihelp Plus Necesse Unif 5.2 gross monthl income onl necesse Gross monthl income of Occupation of Gross monthl income of spouse/partner Occupation of spouse/partner For the purpose of the Necesse option, monthl income means the gross monthl income before an deductions. Proof of income must onl be provided if the monthl income of both the and the registered spouse/partner is less than the highest income categor, since Medihelp will use the highest of the incomes declared to determine the subscription categor. Acceptable proof of income Income from investments: This income must be declared b all individuals, if applicable, and includes interest, dividends and rental income. Letter from an auditor/accountant/income tax adviser Latest tax assessment ITA34 IT3(a) and the past three bank statements Rental income the rental agreement and past three bank statements Income from full-time emploment: Gross monthl income includes all forms of remuneration, such as basic salar, overtime, commission, bonuses, allowances, fringe benefits and one-off paments. Past three official paslips Latest tax assessment ITA34 IRP5 of the previous tax ear Past three commission and bank statements Pensioners: (Pension, annuit) Latest tax assessment ITA34 Past three pension pament advices and additional proof Own business: (Income from vocation/profession, total income from business, irregular income) Latest tax assessment ITA34 Letter from an auditor/accountant/income tax adviser Unemploed: Individuals who receive no income from a vocation/profession/business, who are unemploed or receive an allowance. UIF paments Emploer groups: An proof of income applicable to individuals as indicated above Full-time students: A notice or letter on an official letterhead from the tertiar institution where ou are registered as a full-time student Proof of income applicable to individuals Important: If ou cannot provide acceptable proof of income, our subscription will be calculated according to the highest income categor Medihelp ma require additional proof other than the above Onl official bank statements on which the account holder s initials and surname are indicated, are acceptable. Please indicate clearl on the bank statements which pament(s) refer to our income

3 /18 Page 3 6. details of dependants ou wish to register The following dependants of an ma be registered: Spouse/partner. Father/mother/brothers/sisters/grandchildren of the and whose financial care is entrusted to the (PLEASE NOTE: these dependants of the spouse/partner cannot be registered as dependants of the, and grandchildren of the pa the same subscription as that of an adult dependant, unless legall adopted). Dependent natural children (of the and spouse/partner). Dependent stepchildren (of the and spouse/partner). Adopted children/foster children/children in temporar safe care/children born in terms of a surrogate motherhood agreement (of the and spouse/partner). Official proof of the Court/clerk of the Court/appointed social worker must be provided in terms of the set criteria determined b Medihelp foster children and children in temporar safe care ma be registered as dependants onl up to the age of 21 ears in terms of legislation. In the case of dependants who are not South African citizens, a cop of their passport must be submitted with the completed application form. (spouse/partner)

4 /18 Page 4 6. details of dependants ou wish to register (continued)

5 /18 Page 5 7. banking details 7.1 individual who pas own subscriptions (choose onl one option b marking an X ) I hereb authorise Medihelp to recover the applicable subscriptions paable b me to Medihelp b debit order from m bank account, monthl on the date indicated below. I further authorise Medihelp to increase or decrease the subscriptions, should it be necessar, and recover the amended amount, or an subscriptions in arrears, from m bank account. Please deduct m monthl subscriptions b debit order from m bank account on the following date: On the first workda of the month in which I requested enrolment and thereafter on the first workda of ever subsequent month. On the 25th da of the month prior to m enrolment and thereafter on the 25th da of the subsequent of m membership. On the last workda of the month prior to m enrolment and thereafter on the last workda of the subsequent of m membership. te: Your subscriptions are paable in advance, and if our membership cannot be finalised in time for the deduction date chosen above, Medihelp will make two separate debit order deductions in our first month of membership, namel on the first available workda following the activation of our membership AND on the actual date ou have chosen in the same month. Medihelp will thereafter collect our subscriptions monthl on the date ou have chosen above. If the debit order deduction date falls on a weekend or a public holida, our subscriptions will be deducted on the first workda after the selected deduction date. If no debit order deduction date is selected, Medihelp will make the deduction on the first workda of the month. 7.2 individual whose emploer pas subscriptions M emploer as m authorised agent hereb authorises Medihelp to recover the applicable subscriptions paable b m emploer as m authorised agent to Medihelp b debit order from m emploer as m authorised agent s bank account monthl on the last workda of each month as from the date of enrolment. I authorise Medihelp to increase or decrease the subscriptions, should it be necessar, and recover the amended amount, or an subscriptions in arrears, from m emploer as m authorised agent s bank account. 7.3 banking details for debit order deductions and claims refunds (must be completed b all s) 1. Use this account for all transactions 2. Use this account onl for the recover of subscriptions NB: If ou select this option, please complete our banking details for refunding claims in the table on the right. Use this account for claims refunds onl NB: If ou selected option 2 on the left, please complete our banking details below. Bank Bank Branch Branch code Tpe of account Name of account holder Account number Branch Branch code Savings Cheque Tpe of account Savings Cheque Name of account holder Account number If onl one bank account number is provided, this account will be used both for the recover of subscriptions and for refunding credits. Signature of account holder/authorised signator for recover of subscriptions Signature of account holder for claims refunds

6 /18 Page 6 8. previous/current membership of medical scheme(s) 8.1 Has this application been necessitated b a change in emploment which resulted in the cancellation of our membership of a previous medical scheme? (t applicable to emploees who have retired and are entitled to remain at their previous/current medical scheme.) Who was the member of the previous scheme? Name and surname 8.2 Please provide details of ALL the medical schemes where ou and our dependants are currentl or have previousl been enrolled: NB: The date joined and date ended are important to place ou in the correct enrolment categor. Indicate current if our membership of the particular scheme is still active. Ensure that the dates of our membership at the different schemes do not overlap. Name of medical scheme* Name and surname* Membership number Date joined* Date ended* * This information is compulsor. If not completed, our application for membership cannot be finalised. 8.3 Did our or our dependant s(s ) previous medical scheme appl an late-joiner penalt? If, please provide the following details: Name of /dependant(s) Late-joiner penalt 5% 25% 50% 75% 5% 25% 50% 75% 5% 25% 50% 75% 8.4 Did our or our dependant s(s ) previous medical scheme appl an condition-specific waiting period and was it still active at the time of termination of membership? (The of a specific condition was excluded from benefits for a certain period.) If, please provide the following details: Name of /dependant(s) Condition-specific waiting period (CSW) End date of CSW If the space provided is insufficient, please provide additional information on a separate page.

7 /18 Page 7 9. medical questionnaire All questions must be answered with a or. If, please provide full details. Incomplete, inaccurate information or information which is withheld ma result in the termination of our membership. If the space provided is insufficient, please provide additional information on a separate page. NB: Please complete the following questionnaire to indicate whether ou and/or our dependant(s) mentioned on this application form have a histor of an of the following medical conditions, illnesses or disorders. (Disorder includes affection or condition of illness.) Be advised that an request for hospital admission or chronic medicine authorisation during the first 12 of membership will be subject to a non-declaration of information investigation before the hospital admission or chronic medication will be authorised. Mark with an X 1. Muscle and skeletal/bone sstem, brain, nerve and skin conditions (e.g. back and neck problems, including injuries, arthritis, gout, multiple sclerosis, hip and knee problems, osteoporosis, dermatitis, stroke, epileps, paralsis, tremors)? 2. Gastrointestinal sstem (e.g. gastro-oesophageal reflux, heartburn, ulcer, Crohn s disease, ulcerative colitis, diverticulitis, spastic colon, liver conditions, hernias, piles)? 3. Urinar tract sstem and/or genital disorders (e.g. kidne stones, renal failure, dialsis, prostate disorders, endometriosis, ovarian csts, menstrual disorders, pelvic inflammator conditions, miscarriages)? 4. Chronic illness (e.g. elevated cholesterol, chest pain, heart diseases, pacemaker, diabetes, high blood pressure, asthma, bronchitis, obstructive lung disease, emphsema, sstemic lupus erthematosus, throid, porphria)? 5. Is an female beneficiar indicated in this application currentl pregnant or is pregnanc suspected?

8 /18 Page 8 9. medical questionnaire (continued) All questions must be answered with a or. If, please provide full details. Incomplete, inaccurate information or information which is withheld ma result in the termination of our membership. If the space provided is insufficient, please provide additional information on a separate page. NB: Please complete the following questionnaire to indicate whether ou and/or our dependant(s) mentioned on this application form have a histor of an of the following medical conditions, illnesses or disorders. (Disorder includes affection or condition of illness.) Be advised that an request for hospital admission or chronic medicine authorisation during the first 12 of membership will be subject to a non-declaration of information investigation before the hospital admission or chronic medication will be authorised. Mark with an X 6. Blood conditions/disorders and/or an tpe of cancer (e.g. haemophilia, leukaemia, lmphoma, tissue-specific cancers)? 7. Pschiatric conditions and/or an substance dependenc (e.g. depression, bipolar mood disorder, stress, panic attacks, alcohol and/or drug abuse)? 8. An disorder of the ears, nose, throat, ees and/or teeth (e.g. glaucoma, cataracts, glasses or contact lenses, deafness, retinal conditions, orthodontics, crowns and bridges, maxillofacial and oral surger)? 9. If ou or an of our dependants are HIV positive or have Aids, ou must phone Medihelp on within 21 das from our enrolment date to register on Medihelp s HIV/Aids programme. Should ou fail to adhere to this condition, it will be considered as the non-disclosure of information, which ma result in the termination of our membership. On receipt of this request, Medihelp will determine whether underwriting conditions will be applied, and if this is the case, ou will receive an amended Proof of membership document. 10. Has an person indicated in this application received an surger in the past, or are ou planning to have a surgical procedure done in the next 12?

9 /18 Page 9 9. medical questionnaire (continued) All questions must be answered with a or. If, please provide full details. Incomplete, inaccurate information or information which is withheld ma result in the termination of our membership. If the space provided is insufficient, please provide additional information on a separate page. NB: Please complete the following questionnaire to indicate whether ou and/or our dependant(s) mentioned on this application form have a histor of an of the following medical conditions, illnesses or disorders. (Disorder includes affection or condition of illness.) Be advised that an request for hospital admission or chronic medicine authorisation during the first 12 of membership will be subject to a non-declaration of information investigation before the hospital admission or chronic medication will be authorised. Mark with an X 11. Has an person indicated in this application ever been examined (medical tests, X-ras, scans), diagnosed with and/or treated for an condition or disorder not mentioned in the medical questionnaire (including medicine bought without prescription) that could potentiall result in a medical claim in the next 12? Please note that this medical questionnaire does not constitute an application to register or authorise chronic medicine/pmb services/ planned procedures/ for benefits. Should ou need to obtain authorisation for chronic medicine, please phone Medihelp on once our membership of Medihelp has been finalised, to obtain an application form for chronic medicine benefits. Alternativel, ou can download an application form from the Medihelp website at b registering on the secured website for members. 10. conditions of membership, declaration b and consent for Medihelp to process personal information Medihelp confirms that 1. our and our registered dependant s(s ) personal and medical information will be treated confidentiall and will not be sold to a third part or used for commercial or related purposes; 2. securit measures have been implemented to protect our data and that Medihelp staff and contracted parties have access to our data to process and pa claims, among other things, and that the have signed a confidentialit agreement in terms of which the undertake not to disclose our personal information to an unauthorised parties; 3. our personal information will onl be used for purposes such as processing our application for membership, paing our medical claims, determining whether ou are entitled to benefits, managing risks, and for an communication purposes; 4. the Scheme will accept liabilit for an breach of confidence and will manage such occurrences in accordance with its internal polic; and 5. should ou make use of a Medihelp contracted brokerage s services then relevant membership information will be made available to the appointed brokerage in order to render a service to ou, and an authorised person at the brokerage ma instruct Medihelp to change an of our personal information except for our banking details, unless ou instruct Medihelp otherwise. Your responsibilities as a member of Medihelp: 6. I will ensure that I know all the provisions of Medihelp s Rules and will read all the correspondence from Medihelp, such as newsletters and statements, and I will stud m benefit guide and familiarise mself with the coverage offered b the benefit option that I have chosen. 7. I undertake to abide b the Rules, as amended from time to time and available at on the secured website for members, and to not submit an fraudulent claims or commit an fraudulent acts. 8. I declare that the information provided in this application for membership is accurate and complete. I understand that an false declaration or omission of information ma result in the termination of m membership and that of m registered dependant(s) or an other measures which Medihelp, in its sole discretion, ma decide to take, subject to appeal procedures. I understand that it is m responsibilit to ensure that the details provided in this application are true and complete for mself and m dependant(s), even if this application was completed b m financial adviser, or an other third part on m behalf. I undertake to notif Medihelp in writing should there be an changes in m health status or that of m dependants after m application for membership has been submitted but prior to m membership commencement date. I confirm that the residential address stated on page 1 is the address that I choose for the purpose of serving an legal documentation. I undertake to notif Medihelp in writing should there be an future changes in m personal details and/or banking details and understand that an non-adherence hereto, ma result in m membership being terminated in accordance with provisions of the Medical Schemes Act and Medihelp s registered Rules.

10 /18 Page conditions of membership, declaration b and consent for Medihelp to process personal information (continued) 9. I understand that this application form is valid for a period of 30 das from the date of signature. The period ma be extended, subject to Medihelp s discretion, up to a maximum of 90 das, whereafter the application form will be cancelled and I will be required to submit a new application form. 10. I confirm that neither m dependant(s) nor I will be registered as beneficiaries of another registered medical scheme on the date on which I requested membership of Medihelp. 11. I take note that the monthl subscription fees will be due on the date selected b me at Section 7 of this application form or on the first workda after this date, and thereafter on the same da of ever subsequent calendar month. Should m emploer, as m authorised agent, undertake to pa m subscriptions to Medihelp, I give permission to m emploer to deduct the amount paable to Medihelp from m salar and pa such amount over to Medihelp. I furthermore give permission that Medihelp ma provide the following information to m emploer in order to pa subscriptions: m identit number, m tax certificate information, as well as m dependant s(s ) dates of birth, ages and relationship. I am also responsible for repaing an debt outstanding on m medical savings account should I terminate m membership of Medihelp. 12. I confirm that I am responsible to give advance notice of termination of membership, and that neither m dependant(s) nor I will be registered as beneficiaries of another registered medical scheme while still members of Medihelp. Medihelp s rights as a medical scheme: 13. I am aware that a three-month general and/or a 12-month condition-specific waiting period and a late-joiner penalt ma be imposed on m membership and that of m registered dependant(s) in terms of the Medical Schemes Act, 1998 (Act 131 of 1998). Medihelp ma finalise m membership without issuing a document containing the conditions of m membership in the event that no waiting period and/or late-joiner penalt is imposed. 14. I am also aware that Medihelp ma restrict benefits to be granted and limit amounts/tariffs to be paid in respect of particular services, for example b enforcing co-paments and exclusions. 15. Medihelp s Rules ma provide for various interventions designed to promote cost-effectiveness and appropriateness of services, such as preauthorisation and designated service providers. 16. Medihelp ma also restrict interchanges between benefit options to the beginning of a ear, and require a notice period as set out in the Rules. 17. Medihelp ma refuse to pa a claim that is submitted after the period as prescribed in the Rules. 18. I am further aware that m membership ma be suspended should I not full pa m contributions or debt for a period of a month, and that m membership ma be terminated should I be in arrears for a period of two, and that m account will be handed over for collection. 19. I am aware that Medihelp ma increase its subscriptions annuall at the beginning of the ear. Protection of information: 20. B signing this form, I give permission for Medihelp to share personal information, as defined in the Protection of Personal Information Act, 2013 (Act 4 of 2013), with an third part as nominated b Medihelp. 21. I hereb give permission, and declare that I have obtained the consent of all m dependant(s), that 21.1 Medihelp ma enquire about m health status or that of m dependant(s) at an medical doctor or an person who is in possession of such information, and give permission for the doctor or person concerned to make such information available to Medihelp and its contracted third parties; 21.2 m dependant(s) ma enquire about m personal and medical information and that of an of m dependant(s) at Medihelp s disposal; 21.3 an adviser in the service of a Medihelp contracted brokerage, should I make such an appointment and use their services, ma have access to m personal and medical information and that of an of m registered dependant(s) at Medihelp s disposal, and that such adviser or an authorised person at the brokerage ma instruct Medihelp to change an of m personal information except for m banking details; and 21.4 Medihelp ma disclose m and m dependant s(s ) medical and personal information to medical service providers for the purpose of delivering medical services to me and m dependants and to pa for such services. 22. I understand that the information contemplated in paragraph 21 will onl be used for the purposes as set out in Medihelp s confidentialit statement (on this application form) and that an deviation will be regarded as a breach of confidence. Should Medihelp wish to use the information for an other purpose, Medihelp must first obtain m approval. 23. I agree that all m telephone conversations and/or that of m dependant(s) with Medihelp and/or its contracted third parties ma be recorded. 24. I agree that Medihelp ma, for the purpose of considering m application for membership or conducting underwriting or risk assessments or considering a claim for medical expenses, request information about me and m dependant(s) from medical practitioners, financial advisers, industr regulator bodies or emploers.

11 /18 Page conditions of membership, declaration b and consent for Medihelp to process personal information (continued) 25. I further consent, and declare that I have obtained the consent of all m dependant(s), that Medihelp ma provide an credit bureau or credit providers industr association with an information about m/m dependant s(s ) consumer credit record, including and not limited to information about m/m dependant s(s ) credit histor, financial histor, personal information (excluding medical information) and judgment or default histor. Signature of Date Should ou be appling on behalf of another person as guardian or curator, please complete the following: In our capacit as Guardian Curator ID/passport number Title Mr Mrs Ms Other (specif) A cop of our passport/id document, as well as the document confirming our appointment as guardian/curator, must accompan this application. First name Tel: Code. Fax: Code. 11. undertaking and declaration b adviser NB: If this section is not completed in full b the adviser, no commission will be paid. I declare that 1. the has appointed me as his/her adviser and is entitled to cancel m services at an time; 2. I have signed a valid contract with m Medihelp contracted brokerage; and 3. the has signed the application in person. I take note that the adviser/brokerage indemnifies Medihelp against an non-adherence to the legal requirements as quoted above. Name of brokerage Brokerage code A Adviser code Name and surname of adviser Tel: Code. Fax: Code. Signature of adviser Date Lead reference number In case of a dispute, the registered Rules of Medihelp will appl.

12 /18 Page 12 additional information (If necessar) Membership number Title Mr Mrs Ms Other (specif) Initials Medihelp Enquiries: Fax: Postal address: PO Box 26004, ARCADIA, 0007 Website: Council for Medical Schemes Enquiries: Website: Medihelp is an authorised financial services provider (FSP 15738) uppe marketing A14546