MEDICAL AID FORMS

Medical aid membership / dependent application forms

application form Use Acrobat Reader for a hard copy of our Application form. Please note that the application form will open in a new window.
aansoekvorm Gebruik Acrobat Reader vir ‘n harde kopie van ons Aansoekvorm. Let asseblief daarop dat die Aansoekvorm in ‘n nuwe venster sal oopmaak.
dependant form Use this form to add a dependant to your membership. You will need Acrobat Reader to open this form. Please note that this form will open in a new window.
newborn baby
registration
Register your newborn baby within 30 days of their birth with the Scheme. You will need Acrobat Reader to open this registration form. Please note that the registration form will open in a new window.
child affidavit To be completed for a child with a different surname to the principal member. You will need Acrobat Reader to open this affidavit. Please note that this affidavit will open in a new window.
Please ensure that the relevant parent of the child signs the affidavit.

Member banking details & claims forms

debit order form Make use of this form to change your debit order details. You will need Acrobat Reader to open this form. Please note that the debit order form will open in a new window.
EFT Use this form to give us your bank account details in order to reimburse you for claims. You will need Acrobat Reader to open this form. Please note that the form will open in a new window.

Member injury reports & 3rd party undertakings

injury report To be completed whenever treatment is required due to an injury. You will need Acrobat Reader to open this report. Please note that the report will open in a new window.
mva & 3rd party
undertaking
To be completed by your attorney when a third party claim is initialised, undertaking to reimburse the Scheme on a successful claim. You will need Acrobat Reader to open this undertaking. Please note that the undertaking will open in a new window.

Medical aid benefit option change forms

option change
request
Make use of this form when you want to change from one to another benefit option, subject to the Terms & Conditions of the Scheme Rules. You will need Acrobat Reader to open this form. Please note that this form will open in a new window.