Instructions

Transcription

Instructions

Instructions
Complete and sign the application form and fax cover sheet and fax it to 086 248 4524.
Alternatively scan and email to us at [email protected]
We will contact you shortly thereafter to discuss the status of your application.
Thank you for choosing Medical Aid Online.
FAX COVER SHEET
To:
Medical Aid Online
From:
………………………………………………………………….....
Fax no:
086 248 4524
Tel no:
………………………………………………………………….....
Date:
………………………………………………………………….....
Pages:
…………………
Comments:
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
Auto & General Park, 1 Telesure Lane, Dainfern, 2191
P O Box 11250, Johannesburg, 2000
Fax 086 248 4524 www.jenus.co.za . Reg no. 2004/018981/07
An authorised financial services provider. FSP36088
Directors: AJ Smart | AA Graham Application for membership
Please Note
1. Please complete in BLACK ink
2. Print clearly using CAPITAL letters
3. Only one character per block
4. Leave one block between words
5. Mark with an X where necessary
6. You must complete all sections of the application form
Your Check List
IMPORTANT: We cannot process your application if it is incomplete, incorrect, or if you have not attached the correct documents.
Please use this check list to make sure that you are sending us everything we need.
Have you completed all blocks within these sections?
If applicable, has your broker or intermediary completed
and signed the relevant section of this form?
If your contributions are paid via Persal,
have you provided proof of income (salary advice)?
Have you given us the correct contact details?
Have you attached all ID copies, birth certificates, proof
of residence, bank statement / cancelled cheque, marriage
certificate & previous medical aid details /certificates
Have you chosen one option only?
Do we have your bank details so that we can collect
your contributions and pay your claim refunds?
Have you attached your salary advice?
If you are a government employee,
have you provided a Persal number and
attached a copy of your latest payslip?
Have you signed the form? (Unsigned forms will be
returned to you for signature.)
Have you provided your employer’s details?
Have you attached your previous membership
certificate with the terminated date?
Section 1. Choice of option. Choose one option only.
BonComprehensive
BonClassic
Standard
BonSave
Primary
BonEssential
BonCap If you select BonCap, please note that you may only obtain treatment from a BonCap network doctor and hospital. Contact the Bonitas call centre on
0861 239 333 or visit www.bonitas.co.za for a list of contracted service providers in your area. The following will serve as proof of income for the BonCap option.
•
•
•
•
•
•
Employed members - recent salary or wage advice. Pensionable earnings will be used to determine the income band used to capture the member contribution successfully.
Government pensioners - Pension slip or bank statement
Non-Government pensioners - recent bank statement / current retirement annuity fund / pension confirmation letter with IT34.
Sponsored members - an affidavit. Full-time student members - proof of registration
Where supporting income documents are not received, the member will be defaulted to the highest income band.
Changes will be processed on the date of receipt of the relevant information and not back dated.
Income bands - tick the applicable band
R0 - R5 700
R5 701 - R9 300
R9 301 - R12 700
R12 700+
Section 2. Intermediary – this section must be signed by the broker / agent
Broker code
5 6 7 0 0
Name of brokerage, broker and agent
BROKERAGE / AGENCY STAMP
Jenus Health Pty Ltd
A l e x i a
G r a h a m
Telephone (w)
Fax
Cell
E-mail address
[email protected]
Administered by Medscheme Holdings (Proprietary) Limited
P.O. Box 1101, Florida Glen 1708
Call Centre 0860 002 108
Fax (011) 671 5380
E-mail [email protected]
1
Application for membership cont’d
Intermediary declaration
1.
I acknowledge that I am an accredited healthcare broker contracted to Bonitas Medical Fund as a financial advisor, and that I am licensed by the
Financial Services Board (FSB) in terms of the Financial Advisory and Intermediary Services Act 37 of 2002.
2.
I acknowledge that the applicant has appointed me as his / her financial advisor and that the applicant is entitled to cancel my services at any time.
3.
I confirm that the applicant was provided with my personal details, physical and postal address and telephone number.
4.
I acknowledge that a monthly commission of 3% of the total monthly premium up to a maximum of R69.00 plus VAT will be paid to me in terms of the
Medical Schemes Act 131 of 1998 (or as amended).
5.
I acknowledge that there has been no material misrepresentation of any fact by me and that in the event of material misconduct or unlawful conduct,
I undertake to refund all monies paid in consequence of such misrepresentation or conduct.
6.
The applicant is familiar with the information requested in the application form and all the relevant information was provided by the applicant.
7.
The advice and assistance given to the applicant was impartial and in the best interest of the applicant.
8.
The applicant has personally signed the application form.
Broker’s / agent’s signature
Date
D
D M M
Y
Y
Y
Y
Name of broker / consultant
where applicable
Section 3. Employer information – This section MUST be completed and signed by your employer
If you are an employee of a private company, submit your application form to your human resources / salaries department.
No application form will be processed without your employer’s Stamp.
Name of employer
Division number
Dept. name
Bonitas pay-point code
Employee number
Medical scheme start date
Employment date
Dependants
Adult
Child
Non-subsidised
We confirm that the applicant is employed by us and commenced employment on the above date. Contributions are being deducted according to the
Scheme rules and option chosen. All sections of the application form have been completed.
Telephone number
COMPANY STAMP
Fax number
E-mail address
IT IS MANDATORY FOR THE
COMPANY STAMP TO ENABLE
US TO PROCESS YOUR
APPLICATION ON THE
CORRECT COMPANY
Name of medical scheme /
salary administrator
Designation
Signature
Date signed
D
D M M
Y
Y
Y
Y
Fax (011) 671 5380
2
Section 4. Details of principal member – please leave a space between names
Title
Initials
First name/s
Surname
Marital status
Single
Married
Divorced
Widowed
Cohabiting
Maiden name (if applicable)
ID / passport number
Gender M
Date of birth
D
D M M
Y
Y
Y
Y
I wish to join the Scheme from
D
D M M
Y
Y
Y
Y
F
Telephone (h)
Telephone (w)
Cell
Fax
E-mail address
Postal address
Street address
Tax number
Number of dependants to be
registered (includes spouse,
children and adult dependants)
Please complete for statistical purposes
Language
English
Afrikaans Other: specify
Ethnic group
Black
Coloured
Indian
White
Asian
Section 5. Government employees – attach a current copy of your salary advice
Persal number
Section 6. Dependants you wish to register
An adult dependant is anyone who is 21 years of age or older. Child rates apply to full-time students 21-24 years of age provided the student proof
(registration details) is attached to the application for the current academic year. You are able to register six adults or child dependants on this form.
Provide valid ID numbers and / or passport numbers for all beneficiaries. Acceptance of the dependants will be in accordance with the rules of the
Fund. Please attach copies of ID / passport, marriage certificates, birth certificates, legal adoption or foster care court order documents and previous
membership certificates with the terminated date.
Fax (011) 671 5380
3
1.
Adult
Child
Title
Initials
Surname (if different from principal member)
First name/s
Relationship to principal member
eg. spouse, child etc.
Marital status
Gender M
Single
Married
Divorced
Widowed
Date of birth
F
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
Cohabiting
Tax number (if applicable)
2.
Adult
Child
Title
Initials
First name/s
Marital status
Gender M
Single
Married
Divorced
Widowed
Date of birth
F
Cohabiting
3.
Adult
Child
Title
Initials
First name/s
Marital status
Gender M
Single
Married
Divorced
Widowed
Date of birth
F
Cohabiting
4.
Adult
Child
Title
Initials
First name/s
Marital status
Gender M
Single
Married
Divorced
Widowed
Date of birth
F
Cohabiting
Fax (011) 671 5380
4
Section 7. Medical details
Please note: failure to disclose medical conditions could limit and / or exclude you from receiving certain benefits,
or result in the termination of your membership.
Do you or any of your dependants currently suffer or have suffered from any of the following:
1. A chronic illness? (e.g. raised cholesterol, heart problems, diabetes, high or low blood pressure, asthma, depression, anxiety, systemic lupus
erythematosus, epilepsy, and / or thyroid disorder) If yes, please provide details.
Y
Name of
beneficiary
Name of
condition
Are you currently
receiving treatments?
YES
NO
YES
NO
Date of
1st treatment
Date of last
treatment
Name of
medication
N
Attending
GP/Specialist
2. Gastro-intestinal disorders? (e.g. gastro-oesophageal reflux disease, heartburn, stomach or duodenal disorders, Crohn’s disease, ulcerative colitis,
diverticulitis and / or spastic colon) If yes, please provide details.
Y
N
Name of
beneficiary
Name of
condition
Are you currently
YES
NO
YES
NO
Date of
1st treatment
Date of last
treatment
Name of
medication
Attending
GP/Specialist
3. Muscle, bone, skin or nerve illnesses or disorders? (e.g. back- and neck-related conditions including injury, arthritis, gout, multiple sclerosis, knee or hip
problems, osteoporosis, dermatitis etc.) If yes, please provide details.
Y
N
Name of
beneficiary
Name of
condition
Are you currently
YES
NO
YES
NO
Date of
1st treatment
Date of last
treatment
Name of
medication
Attending
GP/Specialist
4. Urinary or genital disorders? (e.g. Kidney stones, prostate disorders, endometriosis, ovarian cysts, menstrual disorder) If yes, please provide details.
Y
Name of
beneficiary
Name of
condition
Are you currently
YES
NO
YES
NO
Date of
1st treatment
Date of last
treatment
Name of
medication
N
Attending
GP/Specialist
5. Ear, nose or throat disorders? (e.g. glaucoma, cataracts, visual disorders, deafness, rhinitis, orthodontics) If yes, please provide details.
Y
Name of
beneficiary
Name of
condition
Are you currently
YES
NO
YES
NO
Date of
1st treatment
Date of last
treatment
Name of
medication
N
Attending
GP/Specialist
Fax (011) 671 5380
5
6. Blood disorders, cancer, etc.? If yes, please provide details.
Y
Name of
beneficiary
Name of
condition
Are you currently
YES
NO
YES
NO
Date of last
treatment
Date of
1st treatment
Name of
medication
N
Attending
GP/Specialist
7. Are you or any of your dependants pregnant? If yes, please provide details.
Y
Name of
beneficiary
Trimester of
pregnancy
Confirmed pregnancy
YES
NO
YES
NO
Expected date
of delivery
Complications
(if any)
N
Attending
GP/Specialist
8. Have you or any of your dependants had surgery in the past, or are you planning to have a surgical procedure in the next 12 months?
If yes, please provide details.
Y
Name of
beneficiary
Name of
condition
Are you currently
YES
NO
YES
NO
Date of last
treatment
Date of
1st treatment
Name of
medication
N
Attending
GP/Specialist
9. Is there any other condition or symptoms not listed above, for which medical advice, diagnosis, care or treatment has been recommended or received,
or could potentially result in a medical claim in the next 12 months? If yes, provide details.
Y
N
Name of
beneficiary
Name of
condition
Are you currently
YES
NO
YES
NO
Date of
1st treatment
Date of last
treatment
Name of
medication
Attending
GP/Specialist
Current doctor
Name and surname
He / she has been your doctor since D
Telephone
D M M
Y
Y
Y
Y
Please note : If you, or any of your dependants, have been prescribed chronic medication, contact Chronic Medicine Management on telephone
number 0860 002 108; fax number 0800 223 670/680, or e-mail [email protected] to register as a member on the chronic medicine
management programme. Alternatively, visit www.medscheme.co.za to download a chronic medicine application form.
Fax (011) 671 5380
6
Section 8. Previous medical scheme information
Please attach copy of the previous certificate of membership with the terminated date.
Have you as the principal member, or any of your dependants had previous medical aid cover?
Y
N
If yes, please give full details of you and / or your spouse / partner / adult dependants’ membership of previous registered medical aid schemes and attach
a copy of previous membership certificate. Should you need additional space to provide the necessary information, please make a copy of this section and
attach it to your application. It is important that you specify exact membership join and terminate dates for each medical scheme.
Name of beneficiary
Name of scheme
Membership number
Date joined
Date terminated
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
D
D M M
Y
Y
Y
Y
Are you changing your medical scheme due to a change in your employment? If yes is selected, please provide a letter from previous
employer confirming termination of employment or a letter from new employer or new employment.
Y
N
Have condition-specific waiting periods, exclusions or late-joiner penalties ever been imposed by a previous medical scheme/s or medical
scheme applications by your partner / spouse or any of your dependants?
Y
N
Section 9. Bank details of principal member – for refund of claim/s, savings payments and/or debit order instruction
Please provide the following documents:
If account holder details differs from that of principal member, an affidavit is required and the following documentation.
•
Copy of the account holder’s ID
•
Copy of the bank statement / cancelled cheque / letter from the bank / bank letterhead confirming the account holder’s details
•
Account holder’s signature
I instruct Bonitas to electronically collect contributions and to deposit claims and savings refund, via the Electropay system, using the information
provided below. I understand that transfers cannot be done to and from credit card accounts. I also irrevocably authorise Bonitas to adjust
any incorrect transactions and / or correct any electronic transfer or funds errors without prior notice.
Use this account for contribution collections only:
Bank name
Branch name
Branch code
Account type
Account name
Account number
Account holder’s signature
Fax (011) 671 5380
7
Use this account for member refunds
Bank name
Branch name
Branch code
Account type
Account name
Account number
Date
D
D M M
Y
Y
Y
Y
Section 10. Medical fund acknowledgement and declaration
1.
Bonitas takes the protection of personal information very seriously and for this reason all reasonable measures are taken to protect your personal
information and to keep it confidential. Personal information refers to information that identifies or relates specifically to you or your dependants,
for example, name, age, gender, health status, identity number and email address. In short, any information that we know about you or a dependant
will be regarded as your personal information.
We use your information or obtain information about you for the following purposes:
•
•
•
•
•
•
•
•
•
2.
Underwriting (conditions applicable to your membership and benefits)
Assessment and processing of medical services claims
Fraud prevention and detection
Statistical analysis
Audit & record keeping purposes
Compliance with legal & regulatory requirements
Verifying your identity
Sharing information with service providers we engage to process such information, on our behalf or who renders services to us.
You may access the personal information that we hold and request us to correct any errors or to delete this information.
To protect you and your dependants’ personal information, Bonitas has data security measures in place, i.e. access control to restrict the disclosure of personal
information to only authorised individuals, confidentiality agreements with service providers and staff members, and for the purposes of disaster and data
recovery plans.
Section 11. Acknowledgement and declaration
1.
I, the undersigned, hereby make application to be admitted as a member of Bonitas Medical Fund. When admitted I agree to abide by the rules of
Bonitas which is available for me to read on the Bonitas website www.bonitas.co.za or will be provided to upon my request to Bonitas .
2.
I warrant that the information I have provided in this application form, pertaining to me and my dependants is true and correct.
3.
I warrant that I have the explicit consent of my dependants to disclose personal information about them to Bonitas and will on request from Bonitas
provide such consent, in written form, to Bonitas.
4.
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 to the Scheme shall be forfeited to the Scheme.
5.
Bonitas also has the right to claim damages in respect of any loss or damages it may suffer due to my non-disclosure or misrepresentation. Should any
of my or my dependants’ circumstances alter subsequent to the date of filling in this application, prior to or after the acceptance of my membership
by Bonitas, I shall promptly notify Bonitas of the changes. I acknowledge that failure to do so may lead to the termination or amendment of the terms
and conditions of my membership, and Bonitas shall also be entitled to reclaim any amounts it may have erroneously paid to any service provider
on my or my dependants behalf.
6.
I authorise and instruct my employer to deduct and pay over any amounts (that may become due and owing on my behalf) to Bonitas from time to time
and I also authorise any persons, bodies or institutions who may hold retirement funds for my benefit, to deduct and pay to Bonitas all amounts that
may become due and owing to Bonitas from time to time.
7.
I agree that should Bonitas incur any legal costs or expenses to recover any contributions owed by me or any other amount due by me to Bonitas
for whatever reason, I shall be responsible for such costs and expenses on the attorney/client scale. I consent to my details being listed with a credit
bureau should I default in the payment of my monthly contributions or in respect of any money owing to Bonitas.
Fax (011) 671 5380
8
8.
I understand that it is my responsibility as the principal member to ensure that the monthly contributions are received by Bonitas.
9.
Should any contribution be unpaid, it may result in me and my dependants being suspended from Bonitas until all arrear contributions have been
settled. Should two months’ contributions be outstanding, Bonitas shall have the right to immediately cancel my Bonitas membership. I also
understand that should my membership be suspended or terminated, I shall not be entitled to any benefits arising from my membership whatsoever.
10.
I shall inform Bonitas of any changes to my or my dependants’ health or personal status, as required by the Bonitas Rule, within 30 days of the change
in circumstances.
11.
I authorise my and my dependants’ healthcare provider to disclose information to Bonitas and its contracted third parties, provided such information
is treated as confidential at all times.
12.
I agree to provide Bonitas with any medical or historical information or grant Bonitas access to medical information reasonably requested pertaining
to a particular ailment, disease, disorder, condition or disability.
13.
I agree that should I be accepted as a member of Bonitas, I shall provide Bonitas with all information including medical information that Bonitas may
reasonably require for the purpose of carrying out its obligations in terms of the Medical Schemes Act No. 131 of 1998 and the Bonitas rules.
I also agree and understand that I may be required to attend an examination by Bonitas’ medical assessors from time to time.
14.
I declare that my dependants are not beneficiaries of another registered medical scheme.
15.
I understand that the following conditions (underwriting), which will impact my and my dependants’ right to benefits may be applicable to my
membership as prescribed by the Medical Schemes Act No. 131 of 1998:
15.1 a 3 (three) month general waiting period in respect of all benefits;
15.2 a 12 (twelve) month exclusion in respect of a pre-existing condition;
15.3 a late-joiner contribution penalty
16.
I authorise and permit Bonitas to take all reasonable steps to verify information provided by me in this application form.
17.
I agree to submit proof of identification to Bonitas on demand.
18.
I consent to my telephone conversations with Bonitas being recorded and forming part of Bonitas’ records. I also agree that such records shall remain
the sole property of Bonitas.
19.
I consent to my details being listed with a credit bureau should I default in the payment of my monthly contributions or in respect of any money
owing to Bonitas.
20.
I warrant that the information provided above is true and accurate and should my application be accepted by Bonitas, the contents of this application
form shall constitute the basis of my agreement with Bonitas.
21.
As a government employee, I acknowledge that Bonitas will strictly adhere to Persal policies and procedures.
22.
As a direct paying member, I acknowledge that monthly contributions are payable in advance in accordance with the Rules of Bonitas .
23.
I warrant that none of my dependents are members or beneficiaries of another medical scheme.
Section 12. Acknowledgement and declaration
I acknowledge that I have read and understood the content of this application form. If I am illiterate, I confirm that the content of this application form
and the implications thereof have been read and explained to me.
All information declared on the application form will be kept confidential by the medical scheme.
Signed at
on this
day of
20
Signature of principal member
Fax (011) 671 5380
9

Instructions

Transcription

Similar documents

App form BonCap.indd - Affordable Medical Cover

Bonitas Student 2016_small

Company Profile 2014

FAX COVER SHEET No. of Pages Date To

Verification of current employment Fax Cover Sheet Metropolitan

fax cover sheet - 1 Print Form

Price List KK web - Kievits Kroon Country Estate

Hajoca Corporation

FIRST CORP INTERNATIONAL, INC CREDIT APPLICATION

Checkliste Freifläche_en

Scanned Document