/Contents [280 0 R] << 0000145481 00000 n Chronic Illness Benefit application form. /ToUnicode 279 0 R • PMB’s are subject to pre-authorisation and in the case of emergencies the application must be received within 48 hours. endstream endobj 150 0 obj <>/Subtype/Form/Type/XObject>>stream << 0000004954 00000 n 0.5 0.5 9.0859 9.0859 re /49db0ed0ece4285dd6d04c1c127ea7e6 239 0 R x�+T0R(W0THW0 B#0*JUHrЄ��B��]�@!i /V /Off /Subtype /Widget /BC [1 1 1] endstream /F 4 /AP << 1000 1000 1000 1000 1000 1000 1000 277 1000 1000 endstream endobj 147 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0000011783 00000 n /T (date_8_remedchronappliformc_date-1) 267 0 obj /FT /Tx 274 0 obj /FT /Tx 0000008929 00000 n 91 0 R 92 0 R 93 0 R 94 0 R 263 0 obj /W [3 /V () /ImageI] /Q 0 0000007473 00000 n 119 0 R 120 0 R 121 0 R 122 0 R /Type /Page /MK << /Q 0 251 0 obj >> 10 0000004068 00000 n Application for out-of-hospital management of a Prescribed Minimum Benefit condition 2020 D D M M Y Y Y Y Please note that this form expires on 31/03/2021. /T (phonenumber_3_remedchronappliformc_cellp-1) /MaxLen 13 /Subtype /Type1 /Encoding /WinAnsiEncoding /Subtype /Widget /AP << 0000009522 00000 n �)�?X���H1�3*�uQ��T���4����*����ː_��6���g��،m��r�ݘ�c*�\R6�K�h�w$Q�����X�%���~ ��� Please fax this completed and signed form with any supporting documentation to 011 539 2780 or email PMB_APP_FORMS@discovery.co.za 5. 0000005519 00000 n Please FAX completed form to: 086 651 8009 Or mail to: PO Box 38632, Pinelands, 7430 Member telephone: 0860 004 367 Provider telephone: 0860 100 608 MEDICINE MANAGEMENT CHRONIC MEDICINE BENEFIT APPLICATION ONLY COMPLETE THIS FORM IF YOU ARE A FULLY REGISTERED MEMBER OF GEMS D D M M Y Y Y Y D M Y 0000011062 00000 n Minimum Benefits (PMB) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. 1 G /Text Instructions: We cannot process your application if it is incomplete, incorrect or if you have not attached the correct supporting documents. /Text] /PageLayout /OneColumn >> /N 286 0 R 268 0 obj << /N 290 0 R endstream endobj 160 0 obj <>/Subtype/Form/Type/XObject>>stream /Ff 16777216 275 0 obj /ImageC] endobj /P 256 0 R 0000004326 00000 n << /V () /Subtype /Type1 /Type /Annot << /Type /OutputIntent 103 0 R 104 0 R 105 0 R 106 0 R 149 >> 0000013358 00000 n /Rect [431.5098 297.6797 552.1719 309.0742] /FT /Tx stream /AS /Off [556] Please email completed and signed form with any supporting documents to PMB_APP_FORMS@bankmed.co.za or fax it to 011 539 1136 5. /F 4 �\z� 2. /V () >> /Fabc286 273 0 R /DR << /MaxLen 3 0000015214 00000 n /P 256 0 R /Root 252 0 R endobj /MK << /AP << /DW 1000 /Resources << /Rect [129.8789 437.0449 566.5664 448.4395] /Ff 16777216 /Type /Annot Here are your most important forms for easy download: AfA Application form: Application form for HIV+ patients requiring ART. /BC [1 1 1] 181 H�1D���)�Y7��(66‚`��X���')����Q٬]-s�R�T���y`@�*���̽�/�� �ͤuq�k�� �.�ݍU�Tg0�-�ĭ0V2�E^2��N� 0 ^?e 0000006635 00000 n 556 610 556 333 610 610 277 1000 556 277 /DA (/Verdana-Bold 7 Tf 0 0 0 rg) /FitWindow false Your Healthcare professional must complete section 2 and 3 and included detailed documents to support this application for acute and/or ongoing treatment for a Prescribed Minimum Benefit. /Subtype /Widget /ImageC >> << 1000 1000 1000 1000 610 975 722 722 722 722 l ����s ��� >> endstream 0000008757 00000 n Application for out-of-hospital management of a Prescribed Minimum Benefit condition 2020 This is applicable to the Essential and Basic Plans Please note that is form expires on 31/03/2021. >> /Subtype /Widget >> /Text] H�4�1 E�\i\� s >> /P 256 0 R endstream endobj 158 0 obj <>/Subtype/Form/Type/XObject>>stream Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates. 259 0 obj endobj /Flags 32 /DA (/Verdana-Bold 7 Tf 0 0 0 rg) 4. Chronic Illness Benefit application form 2020 7KLVDSSOLFDWLRQIRUPLVWRDSSO\IRUWKH&KURQLF,OOQHVV%HQHILWDQGLVRQO\ YDOLGIRU ' ' 0 0 < < < < MALCIB001 Malcor Medical Aid Scheme, registration number 1547. /TU () /Ascent 728 0000007740 00000 n /Verdana-Bold 249 0 R /Subtype /Form /F 4 /Font << /N << 76 0 R 77 0 R 78 0 R 79 0 R >> >> 3. /Subtype /Widget endobj 264 0 obj Through the navigation of this application you will be able to keep track of your Personal Medical Savings Account details and balance. 556 500 722 500 500 500] /Type /Annot /T (phonenumber_7_remedchronappliformc_telep-2) /AP << /MissingWidth 277 /MaxLen 8 >> 0000126172 00000 n >> /N 289 0 R 1000 277] /BaseFont /XRUJUB+ArialMT >> /82d38e75303d9839b42d6f0e4ef81773 241 0 R 2020 Guide to Prescribed Minimum Benefits 2016 Guide to Prescribed Minimum Benefits - 2020 Guide to Prescribed Minimum Benefits 2019 APPLICATION FORM – CHRONIC MEDICINE BENEFIT 2019 Remedi … /ID [ /NeedAppearances true /FT /Tx [190 333 333] /Type /XObject 261 0 obj 556 556 556 556 556 556 556 556 1000 333 /Parent 237 0 R /Info 250 0 R /Yes 275 0 R 87 0 R 88 0 R 89 0 R 90 0 R >> /F 4 /P 256 0 R << >> endstream endobj 149 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream H�2Tp�2�3U aK=SKU��U�U�e�`�`��K�s�q9�p�G%�$)����Y*��q�Y*�Y�*��p���+��pik*�dq��pr 9� endobj /MaxLen 9 << QD�~�bʵ�I����e��Fv�ZX����bq�p�[���h��]�u�O�����<0���|f�Gv� .ٌ.��X�����A��uǦ��G� �&� /F 4 >> 0000014494 00000 n 0000010782 00000 n /TU () l ��Is ��d [222]] endobj >> >> /T (checklist_1_remedchronappliformc_outcoofthisapplimust-1) 1 G 273 0 obj 0.5 0.5 9.086 9.0859 re /Filter /FlateDecode >> How to complete this form: /Type /Group H�2�37�402VH�2P0P04�3�0�P�� Page 1 of 9 €01.07.2020 Page 1 of 2 €31.12.2020 /Type /Annot /P 256 0 R DHMAOM001 [556 556 500 556 556 277 556 556 222 222 /MK << x�c```f`� �� uD� ٪@,�b ���L}W�!R� ���+��1����f`Q� �@�V rc/��ć���P|��� -� �c�4#T\�MPU���^@��� �$4�``�(���-����� Pl./ tJ(� /Rect [431.5098 418.0703 567.2207 429.4648] 777 666 1000 722 666 610 1000 1000 943 1000 l ��Ks �n D 0000013132 00000 n /Q 0 /MK << endstream endobj 162 0 obj <>stream /FT /Tx /Rect [377.8574 342.8262 387.9434 352.9121] endobj /ZaDb 274 0 R >> Prescribed Minimum Benefits (PMBs) are a set of predefined conditions that form part of South Africa’s Medical Schemes Act.With PMBs, anyone who is part of a medical scheme, no matter what medical aid plan they’re on, can receive treatment for 270 hospital-based and 25 chronic conditions, and the price of these will be covered in full. 139 0 obj <> endobj /MediaBox [0 0 595 842] /MK << << /XObject << The latest version of the application form is available on www.lahealth.co.za. /TU () /Type /Font /ViewerPreferences 253 0 R << >> [277] 0000014950 00000 n /Ordering (Identity) /CA (3) 107 0 R 108 0 R 109 0 R 110 0 R /TU () H�4�� [222] /AS /Off endstream endobj 153 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream >> >> 254 0 obj Benefit (PMB) Chronic Disease List (CDL) conditions registered on the Chronic Illness Benefit (CIB) LHRACF001 LA Health Medical Scheme, registration number 1145, is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. >>] /DA (/Verdana-Bold 7 Tf 0 0 0 rg) endobj 0000007193 00000 n B1D�9Ŕڬ��V! /DA (/Verdana-Bold 7 Tf 0 0 0 rg) >> /Type /Font /Off 276 0 R 2. /FT /Btn 0000006077 00000 n ; AfA PEP Application Form: Application form for post-exposure prophylaxis. endstream endobj 156 0 obj <>/Subtype/Form/Type/XObject>>stream Bariatric surgery application form. 2020 Group application form (editable) 2020 New application form (editable) 2021 Bonitas Change of Option Form: ... 2020 Request for additional pmb cover for hiv: 2020 Request for extended supply of medicine: 2020 Request for pre exposure prophylaxis: 2020 Transfer to individual capacity form: /Type /Annot 57 0 R 58 0 R 59 0 R 60 0 R 0000009986 00000 n 0000012904 00000 n /EvoPdf_eljbpaaclaofkicgabogmhlknllejalf 257 0 R /Off 276 0 R �\z� 4. << 143 0 R 144 0 R 145 0 R 146 0 R /DA (/Verdana-Bold 7 Tf 0 0 0 rg) /CenterWindow false endobj /Type /Annot Chronic Illness Benefit Application form 2020 ' ' 0 0 < < < < ' ' 0 0 < < < < Please note that this form expires on 31/03/2021. endobj /TU () s /Name /XRUJUB+ArialMT >> s 34 0 R 35 0 R 36 0 R 37 0 R You need to complete section 1 of this form. 34 /Font << x��VQo�0~G�?�c:��m06/�ֵ]5�R�f�*MLC��,��; �i�M��&Ap`�}�}w6ܹ��?�C. Application for special payments made from the PMSA. /Rect [423.0039 342.8262 433.0898 352.9121] 0000013586 00000 n The applicant is familiar with the information relating to the Protection of Personal Information (POPI) Act as displayed on www.fedhealth.co.za 8. 262 0 R 263 0 R 264 0 R 265 0 R /HideToolbar false /T (text_9_remedchronappliformc_membenumbe-1) 260 0 obj Remedi SeniorCare is a leading pharmacy innovator servicing long-term care facilities and communities, as well as other adult-congregant living environments. /StemV 80 /MK << H�2Tp�2�3U aK=SKU��U�U�e�`�`��K�s�q9�p�G%�$)����Y*��q�Y*�Y�*��p���+��pik*�dq��pr 9� /Ff 16777216 Permission for third-party access. /F 4 /FontDescriptor 272 0 R 666 1000 1000 1000 1000 1000 1000 1000 556 610 /ItalicAngle 0 Please complete this form for cover of out-of-hospital management of a Prescribed Minimum Benefit (PMB) condition. /N 281 0 R /F 4 /L 282309 666 610 777 722 277 1000 722 610 833 722 /T (checklist_1_remedchronappliformc_outcoofthisapplimust-2) Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates. >> 256 0 obj /FT /Tx /381b21b2e4648d32ae9388afadb4e230 242 0 R 3 0 R 4 0 R 5 0 R 6 0 R 99 0 R 100 0 R 101 0 R 102 0 R /Filter /FlateDecode /FT /Tx Administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. [556 833 722 777 666] /FT /Tx /MK << /Type /Annot 131 0 R 132 0 R 133 0 R 134 0 R /Ff 16777216 277 0 obj /Ff 16777216 72 0 R 73 0 R 74 0 R 75 0 R /Ff 16777216 /N 7 0.5 0.5 9.086 9.086 re H�4ȱ /AvgWidth 277 0.5 0.5 9.0859 9.0859 re << 252 0 obj >> 278 0 R] s /BaseFont /XRUJUB+ArialMT 155 0 R 156 0 R 157 0 R 158 0 R 44058) • Block A, Glenffeld Ofice Park, 361 Oberon Avenue, Faerie Glen, Pretoria, … >> 68 endobj 115 0 R 116 0 R 117 0 R 118 0 R >> /F 4 3. 7 0 R 8 0 R 9 0 R 43 0 R >> >> >> 2. 0 251 45 endobj /MK << 3. /CapHeight 716 �@���a�������� �o\ /Dests << /Registry (Adobe) /Rect [130.5332 418.0703 325.7852 429.4648] 270 0 obj >> Up-to-date forms are always available on www.bankmed.co.za Who we are 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 111 0 R 112 0 R 113 0 R 114 0 R /Encoding /WinAnsiEncoding endstream endobj 152 0 obj <>/Subtype/Form/Type/XObject>>stream /S /GTS_PDFA1 5. /Type /Font /Subtype /Type0 How to complete this application form 1. endobj >> /BaseFont /Helvetica endobj /T (phonenumber_7_remedchronappliformc_cellp-2) endobj /Rect [132.4961 361.1465 566.5664 372.541] /DestOutputProfile 238 0 R >> E�\i\� 182 /Size 296 /Type /Annot /N 285 0 R << /FontName /XRUJUB+ArialMT /Subtype /Widget Quota Seats During Academic Year 2020-21 /Subtype /CIDFontType2 Alternatively members can phone 0860 103 933 and health professionals can phone 0860 44 55 66. /d7fb9ba8ca5562471276649348f6395a 243 0 R /TU () /AP << Application for out-of-hospital treatment* Condition ICD-10 Code Consultation or procedure code** Motivation Quantity 3OHDVHFOHDUO\VSHFLI\ZKDWLVUHTXLUHG IRUH[DPSOHFRQVXOWDWLRQV SDWKRORJ\ UDGLRORJ\DQG RUSURFHGXUH AMSAOM001 Please note that this form expires on 31/03/2021. 135 0 R 136 0 R 137 0 R 138 0 R /EvoPdf_kaokapomcagjkhllaaknnblkidpiigle 246 0 R /ProcSet [/PDF 0000014266 00000 n �@E��}�+c3����nll��N1���"Z�[�*�[M�����`4�/�?��Ę�ϗ��/јw�D5�K�b�B���tÎ���8b` ��e /Fields [258 0 R 259 0 R 260 0 R 261 0 R x�]��n�@��H����!����%��a�d �!���8�~�.�+�O��@W�Ym��}׎���p�i��m��v�ꔝ�G�- endobj /AcroForm 254 0 R /Descent -210 /AP << /XHeight 0 Download the forms you need to do your medical aid business with Medihelp. /Rect [190.7285 399.0957 296.3418 410.4902] [722 666 610 722 666 943 666 666] 6. endstream endobj 157 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 0000001938 00000 n 889 610 610 610 610 389 556 333 610 556 1 G << endstream endobj 154 0 obj <>/Subtype/Form/Type/XObject>>stream /V () /MK << /FT /Btn 95 0 R 96 0 R 97 0 R 98 0 R ; AfA PrEP Application form: Application form for HIV- patients requiring PrEP. >> endstream endobj startxref /Ff 16777216 257 0 obj /MK << /Pages 237 0 R /Subtype /Widget >> /Subtype /Widget /FontFile2 295 0 R /V () /Type /Catalog How to complete this application form 1. 151 0 R 152 0 R 153 0 R 154 0 R /Prev 277227 << /BBox [0 0 20 20] /P 256 0 R My Medihelp application form 2020 Enquiries: 086 0100 678 Fax: 012 336 9534 Email: newbusiness@medihelp.co.za Postal address: PO Box 26004, ARCADIA, 0007 www.medihelp.co.za Thank you for choosing to join Medihelp medical scheme. 139 0 R 140 0 R 141 0 R 142 0 R /Group << << endobj 262 0 obj /AP << Please attach the following documents to this form: /Font << >> /Type /Annot We have developed a Remedi Application which will make managing your plan easier in just a few taps. ] /AP << /Rect [401.4121 399.0957 446.8301 410.4902] Your doctor must complete section 2, 3 and section 4 and include detailed documentation to support your application. ; AfA Pre-ART Application Form: Application form for HIV+ patients who do not yet require ART. 53 0 R 54 0 R 55 0 R 56 0 R 15 /AP << My Medihelp application form 2020 Enquiries: 086 0100 678 Fax: 012 336 9534 Email: newbusiness@medihelp.co.za Postal address: PO Box 26004, ARCADIA, 0007 www.medihelp.co.za Thank you for choosing to join Medihelp medical scheme. /H [4068 258] ... PMB and CDL. /PageMode /UseNone 127 0 R 128 0 R 129 0 R 130 0 R Where you must send the completed application form(s) to You must send the completed PMB application form using either of the following methods: Fax to: 011 539 2780 Email to: PMB_APP_FORMS@ malcormedicalaid.co.za Post to: Malcor Medical Aid Scheme, PMB Department, PO Box 652509, Benmore, 2010. /Subtype /Type1 272 0 obj /HideWindowUI false >> The aim is to provide members with continuous care to improve their health and well-being and to make healthcare more affordable. /V () >> endobj 36 0000012449 00000 n /F 4 61 0 R 62 0 R 70 0 R 71 0 R endstream endobj 159 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream trailer 777 1000 556 500 1000 1000 1000 1000 1000 1000 h�bbd```b``��L{��%�d�&=��_0 &σI0��>�,�g����&c�.1��R�$S[���$�M�]k�&���� ��� /Q 0 /Ff 16777216 0.5 0.5 9.0859 9.086 re H�1D���)�Y7��(66‚`��X���')����Q٬]-s�R�T���y`@�*���̽�/�� �ͤuq�k�� �.�ݍU�Tg0�-�ĭ0V2�E^2��N� 0 ^?e >> %���� endobj 38 0 R 39 0 R 47 0 R 48 0 R 271 0 obj /V () /FT /Tx 0000009802 00000 n endobj >> 1 G 0000002751 00000 n 44 0 R 45 0 R 46 0 R 86 0 R Of out-of-hospital management of a Prescribed Minimum Benefit ( PMB ) condition PMB condition 31/03/2021! 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