Medimed all applications 201

APPLICATION FOR MEMBERSHIP
MEDIMED MEDICAL SCHEME
P.O. Box 1672
7 Lutman Road
CALL CENTRE 041-395 4474
Port Elizabeth
Richmond Hill
E-MAIL ADDRESS [email protected]
Port Elizabeth
www.providence.co.za
SECTION 1 PERSONAL DETAILS
Please select one option by placing an "X" in the appropriate box
SECTION 2 YOUR OPTION
Please select one option by placing an "X" in the appropriate box
*PLEASE COMPLETE A SEPARATE DOCTOR SELECTION FORM FOR FURTHER DETAILS
PLEASE CONSULT THE LATEST
ADDITIONAL MEMBERSHIP CARD REQUIRED?
MEDIMED BENEFIT GUIDE
SECTION 3 PREVIOUS MEDICAL SCHEMES OF PRINCIPAL MEMBER
Please provide full details of previous membership of registered Medical Aid schemes (starting with most recent) and provide proof by attaching your Certificatesof Membership. (Your previous Medical Aid membership card will not be accepted) Years/Months on Medical Aid
Years/Months on Medical Aid
Years/Months on Medical Aid
SECTION 4 YOUR DEPENDANTS' DETAILS
A. SPOUSE DETAILS
B. DEPENDANTS' DETAILS
NOTE: A separate form must be completed for each of the following dependants: Common Law Partner / Adopted Child / Foster Child. Acceptance ofdependants will be decided in accordance with the Scheme Rules.
SECTION 5 MEMBER BANKING DETAILS
APPLICATION FOR ELECTRONIC TRANSFER OF FUNDS
I hereby instruct MEDIMED Medical Scheme to electronically collect contributions or to deposit refunds into my bank account. I understand that credit card accounts may not be used for these transactions. I also irrevocably authorise MEDIMED Medical Scheme to reverse any erroneous transaction and/or to rectify any incorrect electronic transfer of funds without prior notice.
Signature (Member) Date
PLEASE TICK (MORE THAN ONE OPTION CAN BE SELECTED):
USE THIS ACCOUNT FOR CONTRIBUTION COLLECTIONS (PENSIONERS OR PRIVATE MEMBERS)
USE THIS ACCOUNT FOR CLAIM REFUNDS
ACCOUNT TYPE CURRENT CHEQUE SAVINGS TRANSMISSION NOTE : For a cheque account, please attach an original cancelled cheque
SECTION 6 MEDICAL HISTORY (SEE QUESTIONNAIRE)
DECLARATION
By signing below I hereby give permission for, warrant, acknowledge and/or agree to the following: That the information in this application, whether in my own handwriting or not, is complete and accurate.
To undergo a medical examination, at my own expense, should this be required.
To submit proof of good health for me and my dependants and that the Scheme benefits may be limited or excluded in respect of any particular admission to MEDIMED, or MEDIMED may decline to accept me or any of my dependants in That I am required at all times, if accepted as a member, to give MEDIMED all such information and evidence as MEDIMED may require. To this end I hereby authorise the medical practitioner, or any provider who has attended to me and/or my dependants in the past or the future, to provide MEDIMED with such information. I hereby waive the provision of any law or regulation restricting access to such information.
My doctor, or the doctor of a patient who is a dependant of mine, may provide personal and/or clinical information on this Any information concerning this application will remain confidential at all times.
Signature (Member) Date
MEDICAL HISTORY
How often do you consume alcohol ? Please mark Has your weight changed by more than 5kg in the last year? Are you aware of any medical condition(s) which could require medical treatment or surgery? If Yes, please supply details on Page 5.
Identity Number
CONDITION INFORMATION
Have you or any of your dependants ever experienced or been treated for, or are currently suffering from any of the
following conditions?

If Yes, Please tick the appropriate block or specify the conditions, and complete page 5
Cardiovascular and
or Blood disorders
Respiratory problems
(Lungs or breathing)
3. Hearing/speech impairment Ear Infections Sinus problems Allergic rhinitis
Ear, Nose & Throat Other, Specify
Kidney / Urinary
System Other, Specify
Gynaecological
Glandular/
Endocrine Other, Specify
Neurological
(Nervous system) Other, Specify
Gastrointestinal
Joint or spine condition, including Rheumatoid/Osteo-arthritis Musculoskeletal
Recurrent back pain Ankylosing Spondylitis Emotional /
Psychological Other, Specify
Have you ever had, or are you currently undergoing or anticipating any specialised dentist treatment? (e.g. Orthodontic treatment or impacted wisdom teeth) Do you have any congenital, hereditary or physical disability? Do you participate in any hazardous sports or pursuits e.g. mountain climbing, paragliding? Are you aware of any other conditions which may not have been specified on this form? P,
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SECTION 7 EMPLOYER TO COMPLETE AND SIGN
Scheme Join Date Clock/Payroll Number Date of Employment We confirm that the applicant is employed by us and commenced employment on the above date. Contributions are being deducted according to the selected MEDIMED
Rules. All sections of the application form have been completed and signed.
Name of Medical Scheme/Salary Administrator SECTION 8 DECLARATION BY MEMBER
IMPORTANT Failure to disclose all relevant information accurately may adversely affect the benefits available to you and your dependants.
• I hereby apply to MEDIMED Medical Scheme (MEDIMED) for membership for myself and my listed dependants, and agree to abide • I understand that false information could result in my application for membership being rejected or my membership being cancelled. Should this occur, I agree to refund to MEDIMED all relevant payments which MEDIMED made on my behalf.
• I accept any penalties that may be applied in accordance with the Medical Schemes Act of 1998. I understand that these penalties include a 3 month general waiting period, a 12 month waiting period for pre-existing conditions and, if applicable, a late-joiner penalty fee.
• Contributions due to MEDIMED by me or my dependants will be paid MONTHLY. Failure to do so will result in my membership being suspended or terminated as per the MEDIMED Scheme Rules.
• I authorise any doctor, person, party or institution who may have any information about my health or the health of any of my dependants to disclose information required to MEDIMED and I agree that this authority shall remain in force after my death.
• I understand that MEDIMED may provide written notification, to my postal address, of changes to its Rules. Any notice sent to my postal address, shall be considered received by me on the 7th day after the date of posting.
• I agree that in the event that I, or my Employer, appoints an accredited broker to provide intermediary services, the Scheme shall be entitled to pay over to the broker the agreed fee for such services. I confirm that the following documentation is attached to the application form:
• copy of my ID document and my dependants ID documents/Birth Certificates;
• certificates of previous membership of registered medical schemes; and
• proof of income (salary advice)
• Marriage Certificate

I acknowledge and understand that MEDIMED is entitled access to my medical scheme history in terms of the I agree that PROVIDENCE, as the appointed administrator of MEDIMED, is permitted access to this information in order If "Yes" or "No" is not selected above, it will be assumed that I have granted this permission to MEDIMED to access this information.
CHRONIC MEDICATION BENEFIT
APPLICATION FORM
CALL CENTREl: 041-395 4400
P.O. Box 1672
68 Cape Road
E-MAIL ADDRESS: [email protected]
Port Elizabeth
Port Elizabeth
WEB ADDRESS: [email protected]
www.providence.co.za
Administered and Managed by PROVIDENCE Healthcare Risk Managers A. IMPORTANT INFORMATION
1. One application must be completed per beneficiary applying for chronic medication.
2. Allow 5 working days for the processing of your application.
3. The original prescription must be given to the provider who dispenses your medication.
4. It is essential that you submit all required information correctly and timeously as incomplete forms will not be processed.
5. Approval of chronic medication is subject to the rules of the Scheme and PROVIDENCE Chronic Protocols 6. You may contact the Pharmacy Benefit Management (PBM) Team at (041) 395 4482 or email [email protected]
7. Send completed forms via fax 086 680 8855, mail PO Box 1672, Port Elizabeth, 6000 or e-mail [email protected]
B. MEMBER DETAILS
C. PATIENT DETAILS (Beneficiary who requires Chronic Medication)
The outcome of this application must be communicated to me via my email address: OR fax number Yes
PATIENT DECLARATION
By signing below, I hereby give permission for, acknowledge and/or agree to the following:
My (or my minor dependant's) doctor may provide clinical information regarding my/minor's condition to the PBM Team; • Any information concerning this application will remain confidential at all times; It may be a pre-condition to the approval of the Chronic Medication Benefit that I register and comply with the requirements of a Disease Management Programme and that non-compliance may lead to the withdrawal of this benefit; My (or my minor dependant's) doctor retains the responsibility for my (or my minor dependant's) condition, based on the understanding that I (or myminor dependant) also has a responsibility towards my (or my minor dependant's) own health concerns, irrespective of the outcome of this application.
• This funding authorisation is at all times subject to the Scheme rules even if a member’s circumstances change after the authorisation is provided.
This authorisation is not a guarantee of payment.
• This funding authorisation is based on the most appropriate clinical criteria in terms of the Scheme rules and protocols. All treatment decisions reaminn the responsibility of the of the beneficiary’s health care provider irrespective of the funding decision made in terms of the Scheme rules, clinical criteria and protocols.
• PROVIDENCE shall not accept responsibility for any act, errors or omissions, loss, damage or consequences of individual responses to to the treatment authorised or not authorised for funding by the Scheme.
Patient Signature (or member if patient is a minor) ___________________________________________ E. PATIENT HEALTH INFORMATIOB (to be completed by doctor)
Administered by PROVIDENCE Healthcare Risk Managers (Pty) Ltd. Reg. No.1993/006699/07 Version 5 (November 2009) PO Box 1672, Port Elizabeth, 6000 Tel: +27 41 395 4400 Fax: +27 41 395 4597 Patient name
Membership number
CLINICAL CRITERIA
The following information is required when applying for a new chronic condition
Certain conditions which do not appear on the form below may be considered for approval on the Chronic Benefit, although not all long-term
conditions, which a doctor may define as chronic, will fulfill the criteria for approval.
* Chronic conditions only available on the Extended Chronic Benefit of the Medisave Max, Medisave Standard and Medimed Alpha options. Not applicable to Managed Care options. Condition
Requirements
1. Folstein's Mini Mental Examination State (MMSE) result.
1. Lung function test (8 yrs and older).
1. Motivation for 2nd line agents (E.g. Avodart®, Flomax® and Xatral®).
1. Specialist to complete Section J.
1. Please classify according to NYHA or ACC-AHA Classification. 2. Details of diagnosing specialist to be supplied.
1. Details of diagnosing specialist to be supplied.
1. Lung function test including FEV1/FVC and FEV1 post bronchodilator.
2. Initial Specialist (Nephrologist) Application.
2. Attach history of previous cardiovascular disease event(s).
1. Details of diagnosing specialist to be supplied.
1. Details of diagnosing specialist to be supplied.
1. Funding for first line therapy will be allowed for 6 months only. Further funding will only be considered on motivation from a psychologist and/or prescription from a psychiatrist.
2. Prescriber to complete Section J.
1. Attach initial diagnostic report.
1. Prescriber to clearly indicate ICD-10 code.
2. Attach detailed seizure history .
1. Specialist motivation required for treatment exceeding a 6 month period.
1. Supply initial diagnostic intra-ocular pressure.
1. Diagnostic Gastroscopy or Barium Meal Swallow report.
1. Haemophilia A (Factor VIII as % of Normal). 2. Haemophilia B (Factor IX as % of Normal).
1. Prescriber to complete Section G and I.
2. Please attach the diagnosing lipogram. The application cannot be 1. Prescriber to complete Section G and H. 2. Initial Specialist Application if younger than 30 years.
1. Attach report showing T3, T4 and TSH levels.
1. Attach initial diagnostic report.
1. Motivation required for early-onset menopause (< 40yrs) and the prescription of Livifem ®.
1. Extended Disability Status Score (EDSS). 2. Comprehensive disease history. 1. DEXA bone mineral density (BMD) scan and report on any additional risk factors.
1. Initial diagnostic test results confirming RA may be required 2. Initial Specialist Application and motivation where a "stepped therapy" approach has not been implemented. For Enbrel® and Revellex®.
1. Psychiatrist to complete Section J.
1. Details of diagnosing specialist to be supplied.
Administered by PROVIDENCE Healthcare Risk Managers (Pty) Ltd. Reg. No.1993/006699/07 Version 5 (November 2009) PO Box 1672, Port Elizabeth, 6000 Tel: +27 41 395 4400 Fax: +27 41 395 4597 Patient name
Membership number
G. CARDIOVASCULAR (to be compleded by doctor when applying for hypertension, hyperlipidaemia or diabetes mellitus)
G. CARDIOVASCULAR (to be completed by doctor when applying for hypertension, hyperlipidaemia or diabetes mellitus)
Is the patient (if female) post-menopausal? Please indicate which of the following co-morbidities/risk factors apply to this patient?
Prior Coronary Artery Bypass Graft (CABG) If Heart failure is present, please indicate classification below:
Ref: De Marco T, Delgado RM III, Agocha A. et al. J Cardiac Fail. 2004;10 HYPERTENSION (to be completed by doctor when applying for hypertension)
Please supply Two blood pressure readings, performed at least two weeks apart before initiating drug therapy, for newly
diagnosed patient

HYPERLIPIDAEMIA (to be completed by doctor when applying for hyperlipidaemia)
Please attach the diagnosing lipogram. The application cannot be reviewed if this is not submitted.
Is there a family history of early-onset arteriosclerotic disease? If yes, please provide details below:
Does the patient suffer from familial hyperlipidaemia? If yes, please indicate the signs below?
Family history of disorder/ heart attack at early age Please risk your patient as per the Framingham coronary prediction algorithm
J. PSYCHIATRIC CONDITIONS (to be completed by when applying for psychiatric disorders)
Please indicate DSM IV Diagnosis
Please indicate number of relapses
K. ADDITIONAL NOTES
Administered by PROVIDENCE Healthcare Risk Managers (Pty) Ltd. Reg. No.1993/006699/07 Version 5 (November 2009) PO Box 1672, Port Elizabeth, 6000 Tel: +27 41 395 4400 Fax: +27 41 395 4597 Patient name
Membership number
L. MEDICAL PRACTITIONER DETAILS
The outcome of this application must be communicated to me via my email address: OR fax number
CONDITION AND MEDICATION DETAILS (to be completed by doctor)
Date Medication initiated
Medication prescribed (Name, strength & dosage)
& prescriber details
Signature of Medical Practitioner _________________________________________________ HOW THE CHRONIC BENEFIT WORKS
The Chronic Benefit includes cover for medication from a specified list of chronic conditions which is in accordance with the scheme option.
These conditions have been selected according to clinical and actuarial criteria.
Chronic Disease List -
The Prescribed Minimum Benefit regulations require that medical schemes cover the diagnosis, medical management and medication for a specified list of 27 chronic conditions known as the Chronic Disease List.
All such ailments meeting approval criteria will be authorised under the PMB Chronic Medication benefit.
Extended Chronic Disease List -
Certain medical scheme options provide cover for an Extended Disease List which includes some 46 additional chronic conditions. All approved medication will be paid up to the benefit limit on the respective plan.
All such ailments meeting approval criteria will be authorised under the Extended Chronic Medication benefit.
The PROVIDENCE PBM (Pharmacy Benefit Management) team will authorise an amount for all approved chronic conditions.
The approved amount (PCV – PROVIDENCE Chronic Value) is determined based on the treatment protocols for all levels of treatment for each condition. The PCV is the maximum Rand amount that will be approved for the class/category of each drug that is authorised.
Administered by PROVIDENCE Healthcare Risk Managers (Pty) Ltd. Reg. No.1993/006699/07 Version 5 (November 2009) PO Box 1672, Port Elizabeth, 6000 Tel: +27 41 395 4400 Fax: +27 41 395 4597 MEDIMED MANAGED CARE OPTION
DOCTOR SELECTION FORM
IPA CHOICE OF FAMILY:
WINTERHOEK
Principal Member
Medical Aid Number
Employer
Name of Selected Practioner
First Names
MANAGED CARE UDIPA ONLY
DEPENDANTS
Name Of Selected Practitioner
MANAGED CARE UDIPA ONLY
First Names
Optometrist
PLEASE NOTE:
1. Members selecting a provider from the ECIPA list of providers select a General Practitioner from the list provided and can visit any
Dentist on the list or Optometrist from the PPN list.
2. Members selecting a provider from the PEGP list of providers select a General Practitioner from the list provided and can visit any
Optometrist from the PPN list and any Dentist.
3. Members selecting a provider from the UDIPA or WINTERHOEK list of providers must select a General Practitioner, Optometrist and
These members must also note that there is no Medical Savings Account, as these benefits are included in the capitation fee and are provided through your selected practitioner.
4. Families can only change from a Port Elizabeth IPA to an Uitenhage IPA once a year from (to become effective 1 January of each 5. Families choosing an Uitenhage IPA will not have an allocated Medical Savings Account.
Should you require any additional information or assistance please do not hesitate to contact our customer care departments
as follow:

ECIPA and PEGP (041) 395 4474 • UDIPA and WINTERHOEK (041) 991 0455
Signature _____________________________________________Date Y Y Y Y M M D D Administered by PROVIDENCE Healthcare Risk Managers (Pty) Ltd. Reg. No.1993/006699/07 Version 5 (November 2009) PO Box 1672, Port Elizabeth, 6000 Tel: +27 41 395 4400 Fax: +27 41 395 4597

Source: http://www.medimed.co.za/Downloads/MEDIMED_Application_for_Membership.pdf

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