fedhealth member RECORD AMENDMENT FORM

Transcription

1 fedhealth member RECORD AMENDMENT FORM PLEASE MAIL COMPLETED FORM TO: OR FAX TO: Fedhealth Medical Scheme Private Bag X3045 Randburg 2125 Fedhealth Membership Fax No: OR TO: Broker House: Aon South Africa (Pt) Ltd Tel No: Broker Code: AON001M16 Change of address / contact details Change of bank details Change of marital status Sections 1, 2, 8 and 9 must be completed Sections 1, 3, 8 and 9 must be completed Sections 1, 4, 8 and 9 must be completed Termination of dependant membership Registration of: Sections 1, 5 8 and 9 must be completed Births and adoptions Additional adult and child dependants Sections 1, 6, 7, 8 and 9 must be completed SECTION 1 : DETAILS OF PRINCIPAL MEMBER First name/s Initials Preferred name Membership no. SECTION 2 : CHANGE OF ADDRESS / CONTACT DETAILS Telephone (H) ( ) Cellular Telephone (W) ( ) Fax ( ) Postal address Postal code Phsical address Postal code SECTION 3 : BANK DETAILS OF PRINCIPAL MEMBER Refund of claims and debit order instruction I hereb instruct Fedhealth to electronicall collect contributions and to deposit claims and savings refunds, using the information provided below. I understand that transfers cannot be done to and from credit card accounts. I hereb authorise Fedhealth to reverse an erroneous transactions and/ or rectif an EFT errors without prior notice. Note: Direct paing members can select either of the following two dates for debit order collections. 25th of the month OR First working da of the following month Should ou miss a pament, Fedhealth reserves the right to deduct on a different date to collect the missed premium. Bank charges will appl for rejected debit orders. 1. USE THIS ACCOUNT FOR ALL TRANSACTIONS USE THIS ACCOUNT FOR CLAIMS REFUNDS ONLY 2. USE THIS ACCOUNT FOR CONTRIBUTION COLLECTIONS ONLY NB: If ou ticked no. 2 on the left then bank details must be completed here. NB. If ou tick this option, then ou must complete bank details for claims refunds on the right. Bank name... Bank name... Branch name... Branch name... Bank branch code Bank branch code Tpe of account Cheque Transmission Savings Tpe of account Cheque Transmission Savings Name of account holder... Name of account holder... Bank account number Bank account number If onl one bank account is provided, it will be used for both contribution collections and refunds. Account/ s holder s signature Date d d m m

2 SECTION 4 : CHANGE OF MARITAL STATUS Marital status : Single Married Divorced Widowed Common law partner/ spouse Date of marriage : d d m m : Blue Door Plus members: Please note that if ou pa our own contributions and our marital status changes, ou will be required to complete an Income Verification Form. SECTION 5 : TERMINATION OF BENEFICIARY REGISTRATION DUE TO DEATH, DIVORCE, CHILD SELF SUPPORTING ETC. Please attach certified cop of death certificate if termination is due to death Full name/s as reflected on our membership card Date of birth Deletion date (last da of the month) d d m m d d m m d d m m d d m m d d m m d d m m d d m m d d m m Reason for termination SECTION 6 : REGISTRATION OF SPOUSE/ PARTNER/ ADDITIONAL ADULT OR CHILD DEPENDANT Please note: An dependant over the age of 21 must furnish either proof of registration from a full time tertiar institution for the current ear or an affidavit confirming residenc, marital status, emploment status and income. For an dependant, other than our biological children, under the age of 21, ou are required to furnish supporting legal documentation of adoption or foster arrangement; as well as an affidavit confirming residenc, income, emploment and marital status of both child and natural parents 1 Title Preferred name Adult Child* Initials First name/s Relationship to principal member Gender M F ID/ passport/ birth certificate number Date of birth d d m m Cell If adult, is the dependant financiall dependent on the principal member? Yes No Does the dependant receive an income, e.g. pension, salar? Yes No If es, what is the monthl income? R Has this dependant had previous medical aid cover? Yes No If es, please provide details below. Name of previous medical scheme Membership number Date joined Date left Have condition specific waiting periods, exclusions or late joiner penalties ever been imposed on this dependant on application for membership of Yes No an other medical scheme/s? Maxima Basis, Maxima Basis Grid, Maxima Saver, Maxima Saver Grid, Maxima EntrSaver and Blue Door Plus members are required to nominate a FP from the Fedhealth network for themselves and their dependants. Please note that onl visits to a nominated FP will be covered on these options. For a list of FPs on the Fedhealth network visit click on member tools and ou will find the FP locator button on the page. For a list of FPs on the Blue Door Plus FP network, please contact the Customer Contact Centre on NOMINATED FP DETAILS Name Practice number Contact details *Child Dependant = the member s dependent child up to the age of 21 or 27 if a full time student.

3 SECTION 6 : REGISTRATION OF SPOUSE/ PARTNER/ ADDITIONAL ADULT OR CHILD DEPENDANT Continued 2 Title Preferred name Adult Child* Initials First name/s Relationship to principal member Gender M F ID/ passport/ birth certificate number Date of birth d d m m Cell If adult, is the dependant financiall dependent on the principal member? Yes No Does the dependant receive an income, e.g. pension, salar? Yes No If es, what is the monthl income? R Has this dependant had previous medical aid cover? Yes No If es, please provide details below. Name of previous medical scheme Membership number Date joined Date left Have condition specific waiting periods, exclusions or late joiner penalties ever been imposed on this dependant on application for membership of Yes No an other medical scheme/s? Maxima Basis, Maxima Basis Grid, Maxima Saver, Maxima Saver Grid, Maxima EntrSaver and Blue Door Plus members are required to nominate a FP from the Fedhealth network for themselves and their dependants. Please note that onl visits to a nominated FP will be covered on these options. For a list of FPs on the Fedhealth network visit click on member tools and ou will find the FP locator button on the page. For a list of FPs on the Blue Door Plus FP network, please contact the Customer Contact Centre on NOMINATED FP DETAILS Name Practice number Contact details *Child Dependant = the member s dependent child up to the age of 21 or 27 if a full time student. 3 Title Preferred name Adult Child* Initials First name/s Relationship to principal member Gender M F ID/ passport/ birth certificate number Date of birth d d m m Cell If adult, is the dependant financiall dependent on the principal member? Yes No Does the dependant receive an income, e.g. pension, salar? Yes No If es, what is the monthl income? R Has this dependant had previous medical aid cover? Yes No If es, please provide details below. Name of previous medical scheme Membership number Date joined Date left Have condition specific waiting periods, exclusions or late joiner penalties ever been imposed on this dependant on application for membership of Yes No an other medical scheme/s? Maxima Basis, Maxima Basis Grid, Maxima Saver, Maxima Saver Grid, Maxima EntrSaver and Blue Door Plus members are required to nominate a FP from the Fedhealth network for themselves and their dependants. Please note that onl visits to a nominated FP will be covered on these options. For a list of FPs on the Fedhealth network visit click on member tools and ou will find the FP locator button on the page. For a list of FPs on the Blue Door Plus FP network, please contact the Customer Contact Centre on NOMINATED FP DETAILS Name Practice number Contact details *Child Dependant = the member s dependent child up to the age of 21 or 27 if a full time student.

4 SECTION 7 : MEDICAL DETAILS It is compulsor to answer each question. Failure to disclose information is fraudulent and ma result in membership not being granted, or termination of membership without refund of contributions paid. HAVE ANY OF THE DEPENDANTS INDICATED IN SECTION 6 SOUGHT ANY ADVICE, BEEN DIAGNOSED WITH, OR TREATED FOR ANY OF THE FOLLOWING CONDITIONS IN THE PAST 12 MONTHS? 1. A chronic illness? (e.g. raised cholesterol, heart problems, diabetes, high or low blood pressure, asthma, SLE, depression, anxiet, epileps, and/ or throid disorders). If es, please provide details. Yes No Name of beneficiar Diagnosis and date Name of medication Are ou currentl Have ou been Name and contact number of treating GP, 2. Gastro intestinal disorder? (e.g. gastro-oesophageal reflux disease, heartburn, stomach or duodenal disorders, Crohn s disease, ulcerative colitis, diverticulitis and/ or a spastic colon). If es, please provide details. Yes No Name of beneficiar Diagnosis and date Name of medication Are ou currentl Have ou been Name and contact number of treating GP, 3. Muscle, bone, skin or nerve illnesses or disorders? (e.g. back and neck related conditions including injur, arthritis, gout, multiple sclerosis, knee or hip problems, osteoporosis, dermatitis etc). If es, please provide details. Yes No Name of beneficiar Diagnosis and date Name of medication Are ou currentl Have ou been Name and contact number of treating GP, 4. Urinar or genital disorders? (e.g. kidne stones, prostates, endometriosis, ovarian csts, menstrual disorders). If es, please provide details. Yes No Name of beneficiar Diagnosis and date Name of medication Are ou currentl Have ou been Name and contact number of treating GP, 5. Ear, nose or throat disorders? (e.g. Glaucoma, cataracts, visual disorders, deafness, rhinitis, orthodontics). If es, please provide details. Yes No Name of beneficiar Diagnosis and date Name of medication Are ou currentl Have ou been Name and contact number of treating GP, 6. Blood disorders, immune deficienc state, HIV/AIDS, cancer etc? If es, please provide details. Yes No Name of beneficiar Diagnosis and date Name of medication Are ou currentl Have ou been Name and contact number of treating GP, 7. Are ou or an of our dependants pregnant? If es, please provide details. Yes No Name of beneficiar Expected deliver date Attending doctor 8. Are there an other conditions or smptoms not listed above, for which medical advice, diagnosis, care or treatment has been recommended or received, or that could potentiall result in a medical claim in the next 12 months? If es, please provide details. Yes No Name of beneficiar Diagnosis and date Name of medication Are ou currentl Have ou been Name and contact number of treating GP,

5 SECTION 8 : EMPLOYER INFORMATION This section must be completed b our emploer onl if emploer pas our contribution Name of emploer Division code Dept. name Fedhealth Papoint code Emploee number Dependant/s subsidised Yes No Persal number if applicable The above details have been noted and contributions will be adjusted in terms of the scheme rules on d d m m and include arrears, if applicable. Total current contribution: Total new contribution: Arrears (if applicable): Name of medical scheme/ salar administrator Designation R R R Compan stamp Signature... Date signed d d m m SECTION 9 : DECLARATION BY PRINCIPAL MEMBER This section must be completed I DECLARE THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT. Signature of principal member:... Date : d d m m

6 Acknowledgement of appointment Contact us on: 0860 tel arc / , P.O. Box 1874, Parklands, 2121, FSB number: 20555; CMS number: ORG895 I hereb authorise Aon South Africa (Pt) Ltd to be m dul appointed Broker with immediate effect. M ID and membership number I have also been informed of the commission due to Aon, paable b the medical scheme as part of m monthl contribution, is 3% of the contribution to a maximum of R80.00 excl. Vat per month. I have further been issued with a Statutor Notice and Section 13 certificate. Signed at (town or cit) on /mm/dd Signature Permission to make certain information available to Aon South Africa (Pt) Ltd I give consent for the disclosure of information about me. Membership number Medical Scheme Aon Broker Code Title Initials First name(s) (as per identit document) ID or passport number To clarif this, the following information will be made available: Personal examples Benefit examples Financial examples Medical examples Membership number Date of birth ID number Postal and Address Contact details Phsical address Telephone numbers Plan tpe Medical Savings Account amounts available Medical Savings Account choice Scheme Rate or Cost Current Medical Savings Account spent Limits Waiting period: details Wellness benefits Self-pament Gap Above Threshold Benefit Tax certificate and tax reports Banking details Total contribution and breakdown Chronic indicator Chronic condition PMB Chronic condition details Confirmation of claims paid (excluding amount and paid from where) Claims transaction histor Hospital procedures Procedures codes Procedures done in doctor s rooms paid from Hospital Benefit I hereb also authorise Aon South Africa (Pt) Ltd to provide me with an products that the consider appropriate to me. Yes No Signed at (town or cit) on /mm/dd Signature Acknowledgement of Broker Appointment/Aon Healthcare/2016 1