2015 Transmed dependant registration form

Transcription

REPRO Transmed Dependant Registration Form 2014.PDF
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Transmed Dependant Registration Form 2013.pdf
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FA Dependant Registration 8pg 3/2/12 14:40 Page 1
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Membership number
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(For office use only)
DEPENDANT REGISTRATION
Contact details: Customer Service Department 0800 450 010
Physical address: 101 De Korte Street, Braamfontein 2001
E-mail: [email protected]
PLEASE COMPLETE THIS FORM IN FULL AND ENSURE THAT YOUR EMPLOYER HAS COMPLETED SECTION
G TO PREVENT DELAYS IN PROCESSING YOUR APPLICATION.
A. MEMBERSHIP DETAILS (MUST BE COMPLETED)
Surname
First name/s (in full)
Membership number
Current Transmed Medical Fund Plan
State Plus Network
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State Plus Own Choice
Private Network
Guardian
B. ELIGIBLE DEPENDANTS
DEPENDANTS
DOCUMENTS REQUIRED TO REGISTER DEPENDANTS
Biological baby
Copy of birth certificate
Legally adopted child/children
Final adoption order
Husband/wife
The lawful spouse may be registered as a dependant
The spouse’s status as a dependant is terminated on the
date of divorce
Copy of ID
Copy of marriage certificate
Membership certificate from previous medical scheme if applicable
Copy of ID
Member’s partner
Affidavits confirming co-habitation and financial dependency
Where a member and partner reside/co-habitate together
before applying for membership and the member and partner Membership certificate from previous medical scheme if applicable
are financially dependant on one another, the partner may
register as a dependant
Child/children born before or out of wedlock
Affidavit confirming member is the biological parent of child
Stepchild/Stepchildren
Official proof that the child is the biological child of the member’s
spouse
Widow/er
Dependants of a deceased member, who were registered as
his/her dependants at the time of the member’s death, are
entitled to Transmed Medical Fund membership without any
new restrictions, limitations or waiting periods
Copy of ID
Marriage certificate
Death certificate of husband/wife
Proof of income
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Orphan
Children of a deceased member, who were registered as
his/her dependants at the time of the member’s death, are
entitled to Transmed Medical Fund membership without any
restrictions, limitations or waiting periods
Copy of ID
Death certificate of parents
Proof of monthly income
Information of guardian
Disabled child/children
A disabled child over the age of 21 years, who is financially
dependent on the principal member, may be registered as a
dependant
Copy of ID
Proof of disability supplied by a medical practitioner
Immediate family
Immediate family of a member and/or the member’s spouse
in respect of whom the member or the member’s spouse is
liable for family care and support*
A member may register his/her parents/parents-in-law/
brother or sister as dependants if they are financially
dependent on the member or his/her spouse
Proof of dependency must be supplied
Copy of ID
Proof of monthly income
Proof of financial dependency (affidavit)
Membership certificate of previous medical aid if applicable
* Please note that the above family members do not automatically
qualify as your dependants. You need to prove to Transmed
Medical Fund’s satisfaction that you are liable for family care and
support of such a special dependant, as opposed to merely taking
a decision to care for him/her, and that he/she is unable to take
care of himself/herself.
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Children over the age of 21 years
Your dependent child can stay on (and pay child contribution
rates) until the age of 21 years. Dependants older than 21
years who are financially dependent on you will pay adult
contributions (an affidavit as proof of financial dependency and
copy of his/her ID will be required).
Copy of ID
Proof of being a full-time student or proof of financial
dependency (affidavit)
Thereafter, he/she may only remain your dependant if he/she:
• Is registered as a full-time student at a recognised
educational institution and is financially dependent on you,
in which case membership may continue until the age of
25 years (please attach a copy of his/her ID, proof of being
registered as a full-time student at a recognised
educational institution and an affidavit as proof of financial
dependency). Child contribution rates will apply until
he/she graduates or turns 25 (whichever comes first)
You will be required to provide proof of dependency at
regular intervals for children over the age of 21 years
C. REGISTRATION OF SPOUSE/PARTNER/NEWBORN/ADDITIONAL ADULT OR CHILD DEPENDANT
Please complete the following section in respect of your dependant/s:
Dependant 1. Adult
C hild
Title
Initial/s
Surname (if different from principal member)
First name/s
Relationship to principal member
Gender
M F
Date of birth
D D M M Y Y Y Y
Marital status
Single
Married
Divorced
Widowed
Maiden name (if applicable)
ID/passport number
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Co-habitating
Civil union
partnership
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Contact details if different from the principal member
Telephone number (h)
Telephone number (w)
Fax
Cellular number
E-mail address
Postal or physical address
Postal code
Language
E
Monthly income (if applicable)
A
Dependant 2. Adult
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Child
Title
Initial/s
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First name/s
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Gender
M F
K
Date of birth
D D M M Y Y Y Y
Marital status
Single
Married
Divorced
Widowed
Co-habitating
Civil union
partnership
ID/passport number
Fax
Cellular number
E-mail address
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Postal code
Language
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Dependant 3. Adult
Child
Title
Initial/s
First name/s
Gender
M F
Date of birth
D D M M Y Y Y Y
Marital status
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Single
Married
Divorced
Widowed
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ID/passport number
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CMY
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Fax
Cellular number
E-mail address
Postal code
Language
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D. STATE OF HEALTH OF DEPENDANTS (NOT PRINCIPAL MEMBER)
Please complete all the required information by ticking the relevant box.
Failure to disclose pre-existing conditions could limit and/or exclude certain benefits or result in the termination
of your membership.
Was medical advice, diagnosis, treatment or care received or recommended to any of your dependants as per this application form
in the last 12 months?
Please supply the required information by marking the relevant box with an “X”.
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1.
Disorders or problems with the heart or cardiovascular system, e.g. heart murmur, high blood
pressure, high cholesterol, shortness of breath, palpitations, chest pain, angina, heart attack and/or any other
cardiac or blood disorder.
YES NO
2.
Respiratory or lung disorders, e.g. tuberculosis, asthma, persistent cough or other breathing problems,
emphysema, coughing up blood, cystic fibrosis, sinusitis or allergic rhinitis.
YES NO
3.
Disorders of the digestive system, stomach, gall bladder, pancreas or liver, e.g. gastric or
duodenal ulcer, heartburn, hiatus hernia, rectal bleeding, Crohn’s disease, ulcerative colitis, irritable bowel
syndrome, hepatitis, cirrhosis, liver failure or have you ever had a gastroscopy or colonoscopy?
YES NO
4.
Disease or disorders of the kidneys, bladder or reproductive organs, e.g. abnormal urine tests,
kidney stones, nephritis, prostatitis, bladder infections or sexually transmitted diseases.
YES NO
5.
Disorders of the nervous system or brain, e.g. epilepsy, stroke, multiple sclerosis, migraine, headaches,
paralysis, Parkinson’s disease or been advised to have an MRI or CT scan?
YES NO
6.
Mental disorders, e.g. depression, anxiety, panic attacks, schizophrenia, eating disorders, attention deficit
hyperkinetic disorder (ADHD) or post-traumatic stress disorder.
YES NO
7.
Ear, nose, throat or eye disorders, e.g. defective vision, cataracts, glaucoma, retinitis, disorders of the
cornea, hearing loss, ear discharge, otitis media or allergies.
YES NO
8.
Disorders or diseases of the skin, muscles, bones, joints, limbs or spine, e.g. any skin rash, arthritis,
gout, fibromyalgia, any back/neck/hip/knee or other joint trouble, multiple sclerosis, any joint problems or
replacements, acne, eczema or psoriasis?
YES NO
9.
Diabetes, sugar in urine, thyroid or other glandular or blood disorders, e.g. anaemia, bleeding
disorders, growth disorder, Cushing’s disease or Addison’s disease.
YES NO
10.
Cancer, a growth or tumour of any kind including moles removed (malignant/benign).
YES NO
11.
Are any of your dependants currently undergoing or anticipating any specialised dental/maxilla facial
treatment?
YES NO
12.
Have any of your dependants had any accidents (including motor vehicle accidents) in the past 24 months?
If yes, please provide details of injuries sustained.
YES NO
13.
Are any of your dependants taking ongoing medication for any condition not listed in any other question?
YES NO
14.
Have any of your dependants undergone any surgical procedure in the past 24 months?
YES NO
15.
Are any of your dependants awaiting or planning any operation or admission to any hospital in the next
12 months?
YES NO
16.
Is there any other condition or symptom, which is not detailed in any other question, for which medical
advice, diagnosis, care or treatment has already been recommended or received, or could potentially result
in a medical claim within the next 12 months?
YES NO
17.
Gynaecological disorders, e.g. abnormal pap smear or mammogram, endometriosis, ovarian cysts, fibroids,
infertility, disorders of the cervix, menstrual disorders or any abnormality of pregnancy or confinement.
YES NO
18.
Are any of your dependants pregnant? If so, what is the expected date of delivery?
Date:
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If your answer was YES to any of the aforementioned questions, please provide full particulars in the space provided below. Please
use a separate sheet of paper if the space provided is not sufficient.
Question
number
Name of
patient
Illness or
condition/
reason
Date and
duration of
illness or
condition
Name of
treating
doctor,
hospital or
institution
Doctor’s
contact
details
Treatment
recommended
(e.g. medication),
likely
date and
duration of
treatment
E. CHRONIC MEDICATION
Do your dependant/s use chronic medication? If yes, please provide details.
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Dependant
Condition
Period medication used
From:
D D M M Y Y Y Y To:
D D M M Y Y Y Y
From:
D D M M Y Y Y Y To:
D D M M Y Y Y Y
F. DETAILS REQUIRED IF APPLICANT WAS A MEMBER OR DEPENDANT OF ANOTHER MEDICAL SCHEME
Member
name
Medical
scheme name
Membership
number
Termination
or current date
D D M M Y Y Y Y D D M M Y Y Y Y
Joining date
Are your dependant/s changing medical scheme membership due to change in employment?
Y
N
Have condition-specific waiting periods, exclusions or late joiner penalties ever been imposed by previous
medical scheme/s on medical scheme applications by your partner/spouse or any of your dependants?
Y
N
Have you ever been a member of Transmed Medical Fund? If so, please state your membership number:
Certificate/s of membership/s of previous medical scheme/s is/are required.
Please note: Membership cards will not be accepted as a substitute for certificates of membership.
G. FOR COMPLETION BY THE EMPLOYER (AUTHORISED COMPANY SIGNATORY)
I/We warrant that the principal member referred to in this application is an employee of our organisation.
The above details have been noted and contributions will be adjusted in terms of the rules of the Transmed Medical Fund on:
D D M M Y Y Y Y
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Please note: Arrear amounts will be included, if applicable.
OFFICIAL EMPLOYER STAMP
D D M M Y Y Y Y
SIGNATURE OF HUMAN RESOURCES
OFFICER/PAYROLL STAMP
DATE
DESIGNATION
H. TERMS AND CONDITIONS
Please read the clauses below carefully. They contain an acknowledgement of fact or potential liability to pay costs or an
indemnity provision and they may potentially compromise your rights. Please ensure that you fully understand
the consequences of the clauses.
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1.
The answers that I have given here are full, complete and true. I understand that if my dependants are accepted as members
of the Fund, my answers on this form will form the basis of their membership.
2.
I apply for my dependants to join Transmed Medical Fund.
3.
I have been provided with a summary of the rules of the Fund (i.e. benefit guide) and I have been given an opportunity to
consider, familiarise myself with and agree to be bound by the rules, if my application for membership is accepted. I understand
that I may obtain a full copy of the rules in accordance with the Medical Schemes Act. The rules of the Fund are also available
on the website at www.transmed.co.za.
3.1
3.2
3.3
4.
I acknowledge that if my dependants and I do not disclose all the information that is relevant to the assessment of this application,
it will make any contract which may result from this application null and void.
4.1
4.2
5.
If I or my dependants have failed to disclose relevant information and the contract then becomes void, the Fund will
have the right to claim back any amounts that it may have paid to me or any person on behalf of me or my dependants
under such contract.
I will be reimbursed any membership payments made by me, but may be charged a reasonable penalty by the Fund.
I will notify the Fund if any alteration takes place in any circumstances on which the Fund based its assessment of its risk after
the date of this application and before the date of the Fund’s acceptance of the risk. I acknowledge that failure to do so will
make any contract which may result from this application null and void.
5.1
5.2
6.
I understand that the summary of the rules of the Fund will be amended annually.
I also understand that, in the event of a dispute, the rules will be decisive.
The words used in this application have the meaning that the rules give them.
If I or my dependants have failed to disclose relevant changes in circumstances and the contract then becomes void, the
Fund will have the right to claim back any amounts that it may have paid to me or any person on behalf of me or my
dependants under such contract.
I will be reimbursed any membership payments made by me, but may be charged a reasonable penalty by the Fund.
I have been provided with a schedule reflecting the benefits I may become entitled to if this application is accepted. The benefits
have also been explained to me and I have had an opportunity to question and consider them.
6.1
6.2
6.3
6.4
6.5
The monthly contributions I will be expected to pay if this application is accepted, have been explained to me. I have
had an opportunity to question and consider the monthly contributions and I understand the consequences if I fail to
pay the monthly contributions.
It is my sole responsibility as a member to make sure that the Fund receives the monthly contribution.
I will pay all sums that I owe to the Fund on demand. Failure to pay any debt due to the Fund may result in the suspension
of membership and/or handover to a third party for debt collection.
Non-receipt of a single month’s contribution will result in the suspension of the Fund’s benefits.
Non-receipt of two months’ contributions will result in the cancellation of my membership of the Fund.
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If the employer is responsible to pay my Fund contributions, I authorise and instruct my employer to:
7.1.1 from time to time deduct any amounts that I may owe to the Fund from my remuneration or any sums due to me;
7.1.2 pay such amounts to the Fund; and
7.2
I also authorise and instruct any person (such as my employer, a pension fund or provident fund) who holds funds for
my benefit after I cease employment, to pay and continue to pay the amounts referred to in clause
7.1 to the Fund as and when it is due.
8.
If I am accepted as a member I must both now and in future, give the Fund all such information and evidence as it may require
from time to time.
8.1
8.2
8.3
9.
I understand that this is an indemnity. This means that in certain circumstances I will be responsible to pay for claims or damage
incurred by the Fund and/or its agents on request.
9.1
9.2
9.3
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For this purpose, I authorise the Fund and/or its agents to obtain from any person any necessary information that
they may require concerning me or any of my dependants in assessing any risk or claim in relation to this application or my
medical Fund membership. I direct that person to provide the Fund and/or its agents with such information on request.
I authorise any medical doctor or other provider who has attended me in the past or who will attend me in the future,
to provide the Fund and/or its agents with such information as it may require.
I therefore give up the protection afforded to me under the provisions of any law or regulation that restricts the
giving of such information and expressly authorise the Fund to access my information as and when it is necessary.
I will obtain the necessary consent from any of my dependants (who may become members in terms of this application),
which may be required.
If I do not obtain their consent, I will have no claim against the Fund and/or its agents.
If I do not obtain their consent, and if any third party has a claim against the Fund and/or its agents, because my dependants
did not give consent as required, I will be responsible for any costs, fees or other amounts the Fund and/or its agents
may be liable for.
10. I give consent to the recording of all conversations between me and the Fund and/or its agents, and all information obtained
through these conversations will form part of the records of the Fund and/or its agents. I also give consent to all these records
remaining the sole property of the Fund and/or its agents.
11. I will notify the Fund should I or any of my dependants require hospitalisation for a non-emergency event at least 48 hours
before the event. I acknowledge that the failure to do so will result in a reduction of benefits the Fund will pay to me or any
supplier on my or my dependant’s behalf for any procedure undergone.
12. I understand that this application form is valid for 30 days only.
13. I am aware that the Fund may ask for proof of identification during any stage of communication with the Fund.
14. The following may apply to new members:
14.1
14.2
14.3
a three-month general waiting period;
a twelve-month exclusion on a pre-existing condition; and/or
a late joiner contribution penalty.
15. I undertake to give a calendar month’s notice should I wish to terminate my membership.
16. Please note that registration will be delayed should this application be incomplete or if the required documents are not attached.
Should your application reach our offices after the fifth day of the month, you will be registered from the first day of the following
month.
I have read and understood the above clauses, had an opportunity to question and consider them, and I agree to
the consequences of them.
D D M M Y Y Y Y
NAME
SIGNATURE
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2015 Transmed dependant registration form

Transcription

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