Application for Membership

Transcription

1 Application for Membership Please complete in BLOCK LETTERS Administered by: Medscheme Holdings (Pty) Ltd. Tel Fax number COMPULSORY INFORMATION TO BE SUBMITTED WITH THE APPLICATION FORM 1. Copy of identity document for member and all dependants (and/or birth certificates where applicable) 2. Copies of all previous medical scheme membership certificates (in the absence of a membership certificate(s), an affidavit detailing previous history i.e. membership numbers and periods of membership for each medical scheme respectively, as well as a letter from your previous employer(s) confirming these details would suffice). MEDICAL SCHEME PLANS Hospital Plan: Savings Plan: Traditional Plan: Traditional Plus Plan: Platinum Plan: Name of GP: INFORMATION All permanent employees must belong to the Scheme, unless they belong to their spouse s or partner's medical scheme. You have an opportunity to review and change your choice of Plan at the beginning of each benefit year. Once you have selected your Plan for the current benefit year, you will not be allowed to change your Plan. The Scheme offers medical scheme benefits to qualifying members and their dependants. There are clear guidelines as to who qualifies to receive benefits, especially relating to dependants, and you will need to provide certain documentation to prove their financial dependency on you. Your contributions will increase as the number of your dependants increases. You will no longer be a member of the Scheme if: You resign from Nedbank Group Limited or Mutual and Federal You die (your dependants may continue as members of the Scheme) You join your spouse or partner s medical scheme as a dependant. Your last contribution will be for the month in which you leave the Scheme. Benefits will be payable for services up to and including your last day of membership with the Scheme, or employment with Nedbank Group Limited or Mutual and Federal Medical scheme contributions are paid in arrears. WAITING PERIODS This applies to new members and new dependants that: 1. Do not elect to join the Scheme within 30 days of employment. 2. Members and/or dependants who resign from the Scheme to join their partner s or spouse s medical scheme as a dependant even though they are eligible to remain on it and then elect to rejoin the Scheme at a later stage. Waiting periods will apply as follows: If you have never belonged to a medical scheme, no benefits will be paid during the first three (3) months and a waiting period of 12 months will apply for any illnesses and conditions, including pregnancy for which you have been diagnosed or recommended or received treatment within 12 months prior to date of application. The waiting periods will also apply to Prescribed Minimum Benefits. If you change jobs and apply for membership of a new medical scheme within 90 days, there will be no waiting period for any illnesses and conditions for which you have been diagnosed or recommended or received treatment within 12 months prior to date of application. Only the balance of previous waiting periods will apply. The beneficiary will be entitled to Prescribed Minimum Benefits. If you have been a member of a medical scheme for less than 24 months and apply for membership within 90 days (not due to a job change), a waiting period of 12 months will apply for any illnesses and conditions for which you have been diagnosed or or recommended or received treatment within 12 months prior to date of application, as well as the balance of previous waiting periods. The beneficiary will be entitled to Prescribed Minimum Benefits. If you have been a member of a medical scheme for more than 24 months and apply for membership within 90 days (not due to a job change), a waiting period of three (3) months will apply. The beneficiary will be entitled to Prescribed Minimum Benefits. 1

2 A. APPLICANT'S INFORMATION Title: Surname: Identity no: Sex: Male Female Date of birth: Marital Status: Single: Married: Separated: Divorced: Widow/er: Contact number: H Cell W Fax address: Postal address: Code Home address: Code B. EMPLOYMENT DETAILS Payroll number: Branch/Dept. code: Date of employment: Branch/Dept. name: Medical aid start date: Income bracket: R0 - R4 500,99 R R6 000,99 R Account holder's name: Bank's name: Branch name and town: Branch code: Account type: Cheque Savings Transmission Account number: Please note: should the above account details be used for: Debit: Credit: Both: C. DEPENDANT INFORMATION Dependant classification and required documentation A copy of the prospective dependant(s) s identity document must accompany this application, as well as the following: Married in terms of any law or custom Birth/adoption of a child Divorce Copy of marriage certificate or other appropriate proof (Signed and stamped affidavit) Copy of birth certificate or adoption papers or hospital confirmation reflecting the dependant s name Copy of divorce decree Other partner(s) Signed affidavit (see section F) Indigent parents/siblings/children with different surnames Over-age 23 dependent children Signed affidavit (see section F) Signed affidavit (see section F) as well as financial details and education registration documents (if applicable) 2

3 C. DEPENDANT INFORMATION (Continued) 1. Date of birth: Gender: Male Female 2. Date of birth: Gender: Male Female 3. Date of birth: Gender: Male Female 4. Date of birth: Gender: Male Female 5. Date of birth: Gender: Male Female 3

4 D. MEDICAL HISTORY AND GENERAL HEALTH QUESTIONS To be completed by each applicant in respect of him/herself and all his/her dependants. Please complete all the required information by ticking the correct box. If the answer is, yes, please provide details in section E in respect of you and your dependants I understand that if I do not provide full details about all the medical condition known to me at the time of this application, or before acceptance of this application, my membership will be declared null and void. PREVIOUS MEDICAL AID MEMBERSHIP Are or were you or any of your nominated dependants, beneficiaries of a registered medical scheme(s) If yes, a certificate of membership (not membership cards) must accompany this application. The entry date as well as the cancellation date must be indicated on the certificate. Failing the above, waiting periods, unexpired waiting periods and late joiner penalties may be imposed. Was later joiner penalty imposed If yes, provide details of penalty rate: R Reason for termination of my membership/ De-registration as dependant(s) 1. Are you or any of your dependants currently pregnant? Name of person. of months 2. Have you or any of your dependants ever had the following? If yes, provide full details in section G. 2.1 Any disorder of the heart (e.g. heart attack, rheumatic fever, heart murmur, coronary artery disease, chest pain, shortness of breath or palpitations)? 2.2 High blood pressure or disease of the blood vessels (e.g. raised cholesterol, stroke or circulatory disorder)? 2.3 Any respiratory or lung trouble (e.g. asthma, bronchitis, persistent cough, tuberculosis)? 2.4 Any disease or disorder of the digestive system, gall bladder or liver (e.g. actual or suspected gastric or duodenal ulcer, recurrent indigestion, hiatus hernia, Hepatitis B or persistent diarrhoea)? 2.5 Any disease or disorder of kidneys, bladder or reproductive organs (e.g. albumin in urine, 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. chronic headaches, trigeminal neuralgia, epilepsy, migraine, blackouts, loss of consciousness, paralysis, anxiety disorder or depression)? 2.7 Any ear, eye, nose or throat disorder (e.g. ear discharge, defective vision, recurrent tonsillitis, swollen glands, persistent mouth sores, cataracts or any hereditary eye disease, functional nose impairment, chronic sinusitis? 2.8 Any disease or disorder of the muscles, bones, joints, limbs, spine (e.g. rheumatism, arthritis, gout, slipped disc) or other back problems? 2.9 Diabetes, sugar in blood or urine, thyroid or other glandular or blood disorder? 2.10 Any lumps, growths (benign or malignant), types of cancers (incl. Hodgkin s and leukaemia), skin cancers or skin disorders? 2.11 Any tropical disease (e.g. bilharzia, malaria, cholera)? 2.12 Any other condition, illness, disease, disorder, disability or accident, which required medical, radiological, surgical, pathological or dental investigations during the past 12 months? 2.13 Been tested or received or expect to receive any medical advice, counselling, treatment or blood test 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 any of your dependants receiving surgical, medical, major dental implants, chiropractic, optical or gynaecological treatment, procedures, advice or tests? 4. Do you or any of your dependants have any physical (incl. dental) abnormality, deformity, handicap or defect, whether congenital or as a result of an accident, disease or some other cause? If, yes, please provide full particulars in section G. 5. Do you or any of your dependants currently use medication on a daily basis? 6. Has your weight or the weight of any of your dependants changed by more than five (5) kg in the last 12 months? If so, why? 7. Do you or any of your dependants suffer from any other ailment or disease at present? If, yes, please provide full particulars in section G. 8. 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 (5) years? If, yes, please provide full particulars in section G. 9. Are you or any of your dependants expecting to undergo any procedure, operation, confinement or receive any major dental treatment during the next 12 months? If, yes, please provide full particulars in section G. If you answered yes to any of the questions in section D above, please provide details in section E. If additional space is required, please attach a separate sheet of paper to this document. 4

5 E. ADDITIONAL MEDICAL INFORMATION Name or Dependant name Name or Dependant name Name or Dependant name Question number: Type of illness/condition (diagnosis): Date on which illness began: Frequency of attacks (hourly/daily/weekly): Date of last attack: If hospitalised, when and how many days: Duration of illness and condition: Treatment and/or type of medication in the past: Treatment: Condition: Current treatment and/or type of medication received: Treatment: Condition: Approximate monthly cost of treatment/type of medication: Treatment: Condition: Details of operation previously performed: Operations and/or treatment needed in future: Name of attending doctor: Additional information: 5

6 F. AFFIDAVIT(S) Member Grandchild I, the undersigned, hereby warrant that all answers given in this declaration are true, correct and complete in every aspect. Dependant's name: Dependant's ID no: If the dependant is a grandchild, please provide the name of the mother/father: Mother/Father's name: Mother/Father's ID no: Dependants relationship to you: Why do you consider yourself liable for maintaining this person? Monthly amount spent on this person: R Do you receive any assisstance towards the maintenance of this person? If yes please provide details: How long have you been maintaining this person: Does this person live in your home, if yes/no please provide details: If no please provide details: Signature of applicant: Print name: I certify that the Deponent signed this declaration in my presence at PLACE on this the and has acknowledged a. That he/she knows and understands the contents of this declaration; b. That he/she has no objection to taking the prescribed oath; c. Considers the prescribed oath to be binding on his conscience; and Uttered the words I swear that the contents of this declaration are true, so help me God/I truly affirm that the contents of the declaration are true Signature of Commissioner of Oaths Stamp 6

7 F. AFFIDAVIT(S) (Continued) Member Affidavit: Sibling Parent Over-age Dependant Dependant Name and surname: Age: Marital status Single: Married: Separated: Divorced: Widow/er: 1. Why do you consider yourself liable for support of this dependant? 2. Is the dependant currently employed? 3. Is the dependant living with you? If yes, please provide details of position held and monthly Gross income: 4. Are or were you a member or registered as a dependant of medical aid? If yes, please provide the following details: Name of medical aid scheme: Status (i.e. member/dependant): Years of cover: Why do you wish to terminate membership or registration as a dependant: Please attach proof of membership or registration as a dependant. If no please provide details of past medical scheme membership or coverage as a dependant: When was cover terminated? Why was cover terminated? 5. If a student please provide proof of registration. 6. Does the parent earn a state pension? If yes please attach proof. Parent gross monthly income (Please attach proof) R Signature of applicant: Print name: I certify that the Deponent signed this declaration in my presence at PLACE on this the and has acknowledged a. That he/she knows and understands the contents of this declaration; b. That he/she has no objection to taking the prescribed oath; c. Considers the prescribed oath to be binding on his conscience; and Uttered the words I swear that the contents of this declaration are true, so help me God/I truly affirm that the contents of the declaration are true Signature of Commissioner of Oaths Stamp 7

8 F. AFFIDAVIT(S) (Continued) Member Affidavit: Partner Common Law Spouse I, the undersigned, hereby warrant that all answers given in this declaration are true, correct and complete in every aspect Partner s/common Law Spouse's name: Why should your relationship with your partner be regarded as similar to a marriage? Do you consider yourself as having a liability to support your partner? If yes, on what grounds? When was the relationship formalised: Are you in any legally binding relationship with another person? If yes, please provide details: Have any children been borne out of this relationship? I hereby confirm that if our relationship is dissolved, that I will inform my Human Resources Department in order for them to cancel the dependant Signature of applicant: Print name: I certify that the Deponent signed this declaration in my presence at PLACE on this the and has acknowledged a. That he/she knows and understands the contents of this declaration; b. That he/she has no objection to taking the prescribed oath; c. Considers the prescribed oath to be binding on his conscience; and Uttered the words I swear that the contents of this declaration are true, so help me God/I truly affirm that the contents of the declaration are true Signature of Commissioner of Oaths Stamp 8

9 G. DECLARATION BY THE APPLICANT I, the undersigned, hereby make application to be admitted as a member of the Scheme. If admitted, I agree to abide by the Rules of the Scheme. I declare that any false statement in the above application or the non-disclosure of any material information will render my membership null and void, and that any monies paid towards the Scheme shall be forfeited to the Scheme. I warrant that the above answers are true, correct and complete in every respect. I undertake to advise the Administrator of any change in my state of health or that of my dependants which may occur prior to my receiving written acceptance of this application, and that such notification shall give the Scheme the right to reconsider the application and to process new terms of acceptance. I am also aware that my membership shall not commence unless the Scheme notifies me in writing of their acceptance of the risk. I hereby authorise any hospital, physician or any other person who has attended or examined me or any of my dependants to furnish the Scheme or its authorised Representative with all information in respect of my illness or injury, medical history, consultation, prescriptions, or treatment and copies of all hospital or medical records. A photostat copy of facsimile or this Authorisation shall be considered as effective and valid as the original. I am aware of the fact that on joining the Scheme during the course of the calendar year, the maximum benefits to which I may be entitled, shall be adjusted in proportion to the period of membership calculated from the date of admission to the end of the particular benefit year. I am aware that a new born or newly adopted child must be registered within 30 days of date of birth or adoption, failing which my child will not be covered by the Scheme from date of birth. I understand that a late registration will result in my new born or adopted only being registered from the first of the month in which the fully completed application form is received by the Scheme. I accept that any claims for the period prior to date of registration will be for my own account. Upon termination of membership of the Scheme, I agree that my employer may deduct any amount due to the Scheme by me from any monies due to me. I confirm that I am familiar with the conditions and benefits of the Scheme. I declare that neither my nominated dependants nor I are covered by any other medical scheme. I hereby authorise the Nedgroup Medical Aid Scheme to furnish my bank account details to ONECARE if I have selected a Plan administered by ONECARE. I authorise ONECARE to pay any medical scheme benefits that may be due to me to this bank or any other to which I might change the account. I undertake to cancel my membership with the Scheme or that of my nominated dependants immediately upon becoming a member or a dependant of another medical scheme. Signed at PLACE On the D D Day of M M Y Y Y Y Signature of applicant 9