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Member Zone

Membership Application Form

 
1 Start 2 Complete

Section A: Plan selection: Please select on option below:

Section B: Employment Details

Please complete this section. You must submit the completed application form to your HR department if your medical aid is through the employer

Section C: Principal Member Details

This is mandatory if you are a foreign national

Section D: Dependant Details – A child dependant is a person younger than 18

Section D
Name/sSurnameGenderDate of BirthIdentity NumberRelationshipPlanCellphone

Section E: Medical Details:

Please enter the medical history of you and your dependants below. Failure to disclose medical conditions could limit your benefits, exclude you from receiving some benefits or result in termination of your membership.

Chronic Illnesses :
Condition/IllnessPatient/s NameDate of last treatment
Gastro-Intestinal Disorders :
Condition/IllnessPatient/s NameDate of last treatment
Muscle, Bone, Skin or Nerve disorders
Condition/IllnessPatient/s NameDate of last treatment
Ear, Nose or Throat Disorders :
Condition/IllnessPatient/s NameDate of last treatment
Blood Diseases or Cancer :
Condition/IllnessPatient/s NameDate of last treatment
Urinary and Reproductive Disorders :
Condition/IllnessPatient/s NameDate of last treatment

Section F: Previous medical scheme information:

Please provide full details of the previous membership and attach a copy of your previous certificate of membership reflecting the termination date

Section F
Member NameSchemeMember numberJoin dateTermination date

Section G: Banking details for refunds:

If the account holder’s details differ from the main member, a letter from the account holder authorising use of their banking details is required.

Biller Code: 35376                           

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