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Bestmed individual - APPLICATION FOR INDIVIDUAL MEMBERSHIP

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Bestmed individual - APPLICATION FOR INDIVIDUAL MEMBERSHIP Powered By Docstoc
					                                                                                                          BESTmed 1/ Individual
                                                        2297 Pretoria 0001 551 Belvedere Street Arcadia    Pretoria
                                              +27 12 339 9800  +27 12 339 9900    service@bestmed.co.za    www.bestmed.co.za
                                                                      086 000 2378 / 086 000 BEST




                                                                       Where did you hear about BESTmed?
                                                                                 (                 )
                                                      TV Cinema Radio Print & Press Consultant Employer Word of Mouth


                        APPLICATION FOR INDIVIDUAL MEMBERSHIP
                                                 FOR OFFICE USE ONLY
         Member No                 Org. No                 Subcode               Date of Admission         Subscription



Benefit option                                                   Annual income interval                       Annual savings
                       Preferred network                                                                      account
Blueprint                  Prime Cure                                       na                                    None
                                  Provider’s name                                                                 None
Blueprint             CareCross                                                na
                                  Practice no
Millennium Basic                    na               from 1/07/2005                      from 1/07/2005
                                                                                                                Compulsory
                                                  0 - R78 000                          > R78 001
Millennium Standard                 na            0 - R54 000                          > R54 001                Compulsory

Bonus Plus                          na            0-                R33 601- R39 601- R45 601-                  Compulsory
                                                  R33 600 R39 600 R45 600 R51 600 > R51 601
Millennium                          na                         na                          na
Comprehensive                                                                                                   Compulsory

Topcare                             na                   0 - R72 000                   > R72 001                Compulsory

 1. APPLICANT (PRINCIPAL MEMBER) write in BLOCK LETTERS

 Title __________________________________________             Surname _________________________________________

 Full names _________________________________________________________________________________________

 Date of birth of member D D M M Y Y Y Y                      Language preference Eng        Afr

 Marital status ___________________________________           Date of marriage / divorce D D M M Y Y Y Y

 ID number                                                    Gender M F

 Monthly gross income R

 2. ADDRESS AND CONTACT DETAILS (PRINCIPAL MEMBER)

 Residential address ______________________________           Postal address ____________________________________ _____

 _________________________________________________                                                                                 _____

 _________________________________________________                                                                                 _____

                             Postal code                                                        Postal code

 Tel (w) ________________________________________             Tel (h) ___________________________________________

 Cell __________________________________________              E-mail




2006/03/07/ES
                                                                                                                               1
  3. DEPENDANT(S)

  3. DEFull names                                             Gender       Date of birth                           ID number                          Relationship
  (Including surname(s) if different from principal member)                                                                                     (                          )
                                                              M   F    D   D   M   M   Y   Y    Y   Y                                        Spouse   Partner   Child   * Other

                                                              M   F    D   D   M   M   Y   Y    Y   Y                                        Spouse   Partner   Child   * Other

                                                              M   F    D   D   M   M   Y   Y    Y   Y                                        Spouse   Partner   Child   * Other

                                                              M   F    D   D   M   M   Y   Y    Y   Y                                        Spouse   Partner   Child   * Other

                                                              M   F    D   D   M   M   Y   Y    Y   Y                                        Spouse   Partner   Child   * Other

   * Declare other
 4. ATTACH THE FOLLOWING DOCUMENTS IF APPLICABLE

 • A copy of the principal members’ identity document.
 • Student registration if dependant is a student.

 5. PREVIOUS MEMBER STATUS

 NB: If you and / or your spouse / partner and / or dependant(s) are / is at present a member / dependant of a medical scheme
 or were / was a member / dependant of a medical scheme / s in the past two years, a CERTIFICATE OF MEMBERSHIP for
 every person should accompany the application form. (NB: Not a member card!)
 If “Yes” please state:

                            Scheme details                                                          Status                                   Period

 Name of scheme                           Member number                            Member                    Dependant             From                         To




 Were you or was / were your dependant(s) subject to any restrictions / exclusions in another medical scheme?

 YES NO
  __________________________________________________________________________________________________
 If “Yes” please furnish the name of the relevant person and the nature of the restrictions / exclusions.

                                                                                                                                                                                  _____



 6. CLAIM REIMBURSEMENT DETAILS
 Details of my / our bank account________________________________________________________________________

 Account holder _____________________________________________________________________________________

 Bank ______________________________________________________________________________________________

 Branch name and town _______________________________________________________________________________

 Account number

 Branch number

 Type of account                                     Current (cheque)                          Savings           Transmission        (Mark applicable block)

 7. MEDICAL HISTORY OF APPLICANT AND DEPENDANT(S)

 Please Note: All questions in the medical history questionnaire must be answered by stating YES or NO. In case of a YES,
 the full details of the relevant person must be furnished in the space provided. If you or any of your dependant(s) are suffering
 from a chronic condition, a medical report is required setting out details of the condition as well as the estimated annual
 cost of treatment thereof. If the space provided is insufficient, write details on a separate page and attach to this questionnaire.

 Height of applicant (cm)____________________________                                                    Current weight of applicant (kg) ______________________

 Estimated total cost of medical services rendered to your dependant(s) in the past two years.

 Year ___________________ R______________________                                                        Year_____________________ R _____________________

 (Attach summary statement if your dependant(s) belonged to another medical scheme).
2006/03/07/ES                                                                                                                                                                  2
 MEDICAL QUESTIONNAIRE


 Have you or your dependant(s) received any medical treatment or care in the             Indicate with a       Name of patient           Condition                     Level / illness,
                                                                                                                                                              Level / stage of stage of illness
 past 12 months or medical advice relating to any of the to any
 or care in the past 12 months or medical advice relatingfollowing conditions?       “X” in the appropriate                                                     condition, nature treatment,
                                                                                                                                                              condition, nature of of treatment,
 (Refer following conditions? (Refer to question 1 - 20. Question 21 excluded)
 of the to question 1 - 20. Question 21 excluded)                                            column                                    Date       Period      medication dosage and hospitalisation
 1. Congenital physical deviations e.g. bat-ears, valvular heart disease                YES        NO
 2. Abnormality of skin (including allergies) e.g. eczema, psoriasis                    YES        NO
 3. Deviations in skeleton, joints and muscles e.g. arthritis, back problems            YES        NO
 4. Sense organs: Sight, hearing, speech, also state spectacles and /                   YES        NO
    or contact lenses as well as visual strength reading if available
 5. Respiratory organs and cardio-vascular systems e.g. hypertension,                   YES        NO
    cholesterol, asthma
 6. Digestive system e.g. hiatus hernia, stomach ulcer                                  YES        NO
 7. Bladder, kidney and sexual system                                                   YES        NO
 8. Nervous system e.g. paralysis, epilepsy                                             YES        NO
 9. Hormone system                                                                      YES        NO
 10. Psychiatric or psychological treatment e.g. depression, anxiety                    YES        NO
 11. Substance dependance e.g. alcohol, drugs                                           YES        NO
 12. Dental treatment                                                                   YES        NO
 13. Metabolic diseases, obesity, diabetes, porphyria                                   YES        NO
 14. A condition for which you and your dependant(s) receive a payment and /            YES        NO
     or medical treatment of whatever nature e.g. IOD claim, third party claim
 15. Are you or your dependant(s) pregnant or is there any suspicion of pregnancy?      YES        NO
 16. Previous abnormal pregnancies                                                      YES        NO
 17. Contagious diseases e.g. HIV, Hepatitis B, Tuberculosis                            YES        NO
 18. Operations undergone                                                               YES        NO
 19. Are you and or your dependant(s) currently being treated for something?            YES        NO
 20. Present medication                                                                 YES        NO
 21. Any other medical condition not mentioned above, even though
     you or your dependant(s) did not receive treatment or advice or consulted a        YES        NO
     doctor in the past 12 months.

 22. Do you and / or your dependant(s) participate in professional or dangerous                               Nature of the sport   Person(s) participating                  Injuries
     amateur sport, like power-driven vehicle sport, glider sport, scuba diving,        YES        NO
     bungee or parachute jumping? If so, provide detail:


 Date: D D M M Y Y Y Y                                                               Signature of member:
2006/03/07/ES
                                                                                                                                                                                                      3
8. STATEMENT BY APPLICANT

I, ________________________________________________________________________________hereby declare that:

a.    Should I be enrolled as a member of BESTmed, I shall subject myself to the rules of BESTmed;

b.    The information furnished herein is completely true and correct to the best of my knowledge and conviction and that
      I have not omitted or concealed any information. I unconditionally accept membership for 12 months and understand
      that a savings account will be allocated pro rata (if applicable);

c.    I understand that should my application for membership be approved and accepted, the information furnished on my
      application form will be used as the basis of my application and the payment of benefits in the future;

d.    I irrevocably hereby grant permission on myself as well as my dependant(s) behalf (if applicable) to any physician, person
      or party who may be in possession of or obtain information concerning my state of health or that of my dependant(s),
      treatment received or expected as well as any other relevant information to divulge such information to BESTmed or
      its proxy on demand, also after my death or that of any of my dependant(s). I understand that this information together
      with other information will be used to evaluate the payment of benefits for certain sickness conditions. I guarantee that
      I have obtained my dependant(s) consent to grant this authorisation;

e.    I undertake to pay my share of accounts to BESTmed, on default, I hereby authorise my employer / undertaking to
      deduct the amount due from my salary or should I resign, I hereby authorise my employer / undertaking to deduct
      the amount due from my pension or any other moneys due to me and pay this over to BESTmed;

f.    If after my admission as a member of BESTmed it is found that any statement or information furnished by me was
      knowingly and willfully inadequate or untrue, I agree to refund in full to BESTmed all payments which BESTmed may
      have made on my behalf and to relinquish any claim to any benefits on the part of BESTmed and;

g.    Any deterioration or change in my state of health or in that of any dependant(s) before the date or event to be set by BESTmed
      for commencement of membership, or the date of acceptance of this application by BESTmed, or the date of receipt
      of the first subscription, whichever date is the latest shall entitle BESTmed to reconsider the application and propose
      new terms of admission or declare the membership null and void in which case all moneys paid to BESTmed
      in connection with this membership before BESTmed is informed of the change, shall be forfeited and benefits paid by
      BESTmed shall immediately be refunded to BESTmed;

h.    BESTmed reserves the right to cancel membership should it become apparent that false information was willingly supplied
      on application.



      Summary of monthly cost:

      1. High risk benefits (principal member or principal member and spouse / partner)

        (emergency evacuation included)

      2. Monthly savings account

      3. Child subscription

      4. Administration fee for individual members @ R42,50 or

      5. Administration fee for individual members @ R62,50

      6. Health & Wealth Programme booster option @ R79,00 / family

      7. Other



      MONTHLY TOTAL (1-7)

Signature of applicant                                              Signature of witness



Consultant name                                                     Consultant code



Consultant signature                                                Date D D M M Y Y Y Y

2006/03/07/ES                                                                                                                    4
                       GOVERNMENT AUTHORISATION FOR DEDUCTIONS

 EMPLOYEE DETAILS
 Employee’s surname

 Full names

 Office / paypoint

 Paypoint number

 Persal number

 Identity number

 First aid kit   YES   NO



 AUTHORISATION TO RECOVER SUBSCRIPTIONS FROM SALARY


 I, hereby authorise BESTmed to deduct my portion of the full monthly contribution and any arrears, for the plan and to pay
 it to the ADMINISTRATOR. I acknowledge that any arrears will be recovered by way of double deductions until fully recovered.
 This authorisation will remain valid until written authority is received from the Medical Scheme.




 Signature of member                                           Date




 Employee’s contribution                                     Employer’s contribution




 Total Contribution




2006/03/07/ES                                                                                                            5
                                                                                    DEBIT ORDER
 1. APPLICANT (PRINCIPAL MEMBER) write in BLOCK LETTERS

  Initials and surname

  Address

  Occupation                                                                   Employer                                                 Period employed

  2. CALCULATION OF MONTHLY DEBIT ORDER
  NAME OF BENEFIT OPTION ______________________________________________
  1. High risk benefits (Principal Member or Principal Member and Spouse / Partner)
      (emergency evacuation included)
  2. Monthly savings account
  3. Child subscription

  MONTHLY TOTAL (1- 3)

  First aid kit          YES         NO

   3. DETAILS OF BANK ACCOUNT
  Account holder                                                                                        Bank
  Branch name and town
  Account number                                                                                       Branch number
  Type of account                          Current (cheque)                               Savings                      Transmission
  (Mark applicable block)

  I / we hereby authorise BESTmed to draw against my / our account with the above-mentioned bank (or any other bank or branch to which I / we may transfer my / our
  account) the sum of R.................................................. on the first working day of each and every month, commencing on DD/MM/YYYY. I / we further authorise
  BESTmed to adjust the amount due as subscriptions are amended from time to time. All such withdrawals from my / our account by BESTmed shall be treated as though
  they have been signed by me / us personally. I / we agree to pay bank charges relating to this debit order instruction. This authority may be cancelled by me / us by giving
  BESTmed sixty days notice in writing, sent by prepaid registered post, provided that this may not be done within twelve calendar months without the written permission
  of BESTmed. Should there be a breach of this contract there is a possibility that the member will be held responsible for payments incurred. I / we understand that I / we
  shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force if such amounts were legally owing to BESTmed. I / we acknowledge
  that the party hereby authorised to effect the drawing(s) against my / our account may not cede or assign any of its rights to any third party without my / our prior written
  consent and that I / we may not delegate any of my / our obligations in terms of this contract / authority to any third party without prior written consent of the authorised
  party.

  Signed at                                                                                     on the                        day of                                                              20

  Assisted by (where legally necessary)

  Capacity                                                                             Tel no

                          Signature of Principal Member                                                                                 Signature of Account Holder

  Note: A cancelled cheque or proof of your savings / transmission account must be attached for the bank identification purposes. This form must bear the stamp of your bank (savings - or transmission account).




                                                          * Your initial payment must accompany your application
2006/03/07/ES                                                                                                                                                                                                 6
                                                                                    Medstra Business Administrators (Pty) Ltd
                                                                                              6

                                                                                               Reg no. 2005/029076/07


                                                                                           DEBIT ORDER
    1. APPLICANT (PRINCIPAL MEMBER) write in BLOCK LETTERS
   Initials and surname

   Address

   Occupation                                                                   Employer                                                 Period employed

    2. CALCULATION OF MONTHLY DEBIT ORDER


   1. Administration fee for Individual Members @ R42,50 or
   2. Administration fee for Individual Members @ R62,50
   3. Health & Wealth Programme booster option @ R79,00 / family

   4. Other



   MONTHLY TOTAL (1- 4)
    3. DETAILS OF BANK ACCOUNT

   Account holder                                                                                       Bank
   Branch name and town
   Account number                                                                                       Branch number


   Type of account                          Current (cheque)                               Savings                      Transmission
   (Mark applicable block)

   I / we hereby authorise Medstra to draw against my / our account with the above-mentioned bank (or any other bank or branch to which I / we may transfer my / our account)
   the sum of R..................................................on the first working day of each and every month, commencing on DD/MM/YYYY. I / we further authorise Medstra to
   adjust the amount due as fees are amended from time to time. All such withdrawals from my / our account by Medstra shall be treated as though they have been signed by
   me / us personally. I / we agree to pay bank charges relating to this debit order instruction. This authority may be cancelled by me / us by giving Medstra sixty days notice
   in writing, sent by prepaid registered post, provided that this may not be done within twelve calendar months without the written permission of Medstra. Should there be
   a breach of this contract there is a possibility that the member will be held responsible for payments incurred. I / we understand that I / we shall not be entitled to any refund
   of amounts which you have withdrawn while this authority was in force if such amounts were legally owing to Medstra. I / we acknowledge that the party hereby authorised
   to effect the drawing(s) against my / our account may not cede or assign any of its rights to any third party without my / our prior written consent and that I / we may not
   delegate any of my / our obligations in terms of this contract / authority to any third party without prior written consent of the authorised party.

   Signed at                                                                          on the                                           day of                                                    20

   Assisted by (where legally necessary)

   Capacity                                                                             Tel no


                           Signature of Principal Member                                                                                 Signature of Account Holder


   Note: A cancelled cheque or proof of your savings / transmission account must be attached for the bank identification purposes. This form must bear the stamp of your bank (savings-or transmission account).




                                                        * Your initial payment must accompany your application
2006/03/07/ES                                                                                                                                                                                               7
          2297 Pretoria 0001 551 Belvedere Street Arcadia   Pretoria
+27 12 339 9800  +27 12 339 9900    service@bestmed.co.za   www.bestmed.co.za
                        086 000 2378 / 086 000 BEST

				
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