Fillable Application for Continuation Membership (Law for All South Africa)

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Application for Continuation Membership (Law for All South Africa)

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Country of origin: SOUTH-AFRICA
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Application for
Continuation Membership
Membership Number
Member Details
Surname
Title/Rank
Residential Address of
Married
Single
Widow/er
Widow/er
Email SMS
Date
D D M M YYYY
Identity Number
Marital status (If divorced attach a copy of final order of divorce with the addendums, if any)
Date
Code
D D M M YYYY
Date of marriage/divorce
D D M M YYYY
Please indicate how you wish
to receive your correspondence
First Names (in full)
Initials
Pension Number
Date of service termination or date of main member
Gender
Male
Female
Postal Address
Tel (Home) Tel (Work)
Fax
Cellphone
Email
Is your cellphone web-enabled (WAP)
Residential Address Postal Address
Yes No
Code
Membership Type
Pensioner
Medically Boarded
Severance Package Orphan
Principal Member or
Guardian (if orphaned)
Principal Member or
Guardian (if orphaned)
03/08
Healthy members for a safer South Africa
Page 1 of 6
Email: polmedmembership@medscheme.co.za • Fax: 0860 888 110 • Post: Private Bag X16, Arcadia, 007
PLEASE NOTE: It is compulsory to complete ALL sections of this form to prevent delays in processing your application. This form should be
completed by pensioners or members who received a severance package, dependants of deceased members or medically boarded members.
Please supply the following documents if applicable:
• Member: Copy of ID, Proof of income, letter form Medical Board (Ill Health) and Service certificate.
• Orphaned children: copy of the birth certificate or a copy of ID (issued by the Department of Home Aairs and proof of monthly income).
• Children born out of wedlock: copy of the birth certificate or a copy of ID and an adavit stating that the member is the biological parent of the child.
• Dependant of deceased member: copy of main member’s death certificate and proof of income (GPAA).
• Marriage: copy of marriage certificate or customer union certificate issued by the Department of Home Aairs and copy of ID.
• Dependant between 21 and 25 years who is studying: copy of ID and a certificate of registration.
• Dependant over the age of 21 who is financially dependent on the member: copy of ID and adavit confirming financial dependency and
monthly income.
• Bank account details: copy of most recent bank statement or stamped letter from bank confirming banking details.
Application for
Continuation Membership
Current/Cheque Account
Savings
Transmission
I hereby authorise POLMED and/or its agents to credit/debit the above account as and when applicable.
Authorised Signature
BANKING ACCOUNT DETAILS: It is required for the direct crediting of member refunds and the direct
debiting of the amounts due to the Scheme. Contributions are due monthly in advance. Claims paid by you
will be credited to the banking account supplied below. For direct paying members, your account will be
debited if you owe money to POLMED.
Payment Details
Bank Account Number
Name of Bank
Branch Number
Type of Account
Principal member or
Guardian (if orphaned)
Name
No person may belong to dierent medical schemes at the same time.
Surname Full First Name ID Number
Current SAPS
employee (Y/N)
Relationship
(e.g. son/daughter)
Gender
Details of Dependant(s)
03/08
Postal Address
Cellphone
Email
Relationship to principal member, e.g. mother/spouse
Please indicate your basic monthly salary/income (include payslip)
Code
Next of Kin’s Details
Income Category
Surname and initials
R
Healthy members for a safer South Africa
Page 2 of 6
Application for
Continuation Membership
03/08
Pre-existing Medical Conditions
YES NO
YES NO
The scheme reserves the right to impose waiting periods as defined in the rules. Should any of these apply
to you, you will be notified in writing by the Scheme within one month of registration.
Medical History and General Health
To be completed by each applicant in respect of himself/herself and all his/her dependants. Please
complete all the required information by inserting a tick in the relevant box. If the answer to any question
is “YES”, provide details overleaf.
I understand that if I do not provide full information about all medical conditions known to me at the time of this
application or before acceptance of the application, my membership may be declared null and void.
1. Have you or any of your dependants ever experienced any of the following in the past 12 months?
1.1 Any disorder/dysfunction of the heart (e.g. heart attack, rheumatic fever, heart
murmur, coronary artery disease, chest pain, shortness of breath or palpitations)?
1.2 High blood pressure or disorder/dysfunction of the blood vessels
(e.g. high cholesterol, stroke or circulatory disorder/dysfunction)?
1.3 Any respiratory or lung disorder/dysfunction (e.g. asthma, bronchitis, persistent
cough or tuberculosis)?
1.4 Any disorder/dysfunction of the digestive system, gall bladder or liver
(e.g. actual or suspected gastric or duodenal ulcer, recurrent indigestion,
hiatus hernia, hepatitis B or persistent diarrhoea)?
1.5 Any disorder/dysfunction of the kidneys, bladder or reproductive organs
(e.g. albumin in urine, stones, prostatitis, pancreatitis or venereal disease) or
gynaecology-related symptoms or conditions (i.e. problems with female organs)?
1.6 Any nervous, mental or other neurological disorder/dysfunction
(e.g. epilepsy, migraine, blackouts, loss of consciousness, paralysis, anxiety
disorder/dysfunction or depression)?
1.7 Any eye, ear, nose or throat disorder/dysfunction (e.g. ear discharge, defective
vision, recurrent tonsillitis, swollen glands, persistent mouth sores, cataracts or
any hereditary eye disease, functional nose impairment or chronic sinusitis)?
1.8 Any disorder/dysfunction of muscles, bones, joints, limbs or spine (e.g. rheumatism,
arthritis, gout, slipped disc or other back trouble)?
1.9 Any lumps, growths (benign or malignant), types of cancers (including Hodgkins and
leukaemia), skin cancers or skin disorders/dysfunctions?
1.10 Any tropical disease (e.g. bilharzia, malaria or cholera)?
1.11 Any other condition, illness, disease, disorder/dysfunction, disability or accident
which required medical, radiological, surgical, pathological or dental investigations
during the past 12 months?
2. Are you or your dependants receiving any surgical, medical, major dental (including
implants), chiropractic, optical or gynaecological treatment, procedures, advice or test?
3. Do you or any of your dependants have any physical (include dental) abnormality,
deformality, handicap or defect, whether congenital or as a result of an accident, disease
or some other cuase?
4. Do you or any of your dependants currently use medication on a daily basis?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Healthy members for a safer South Africa
Page 3 of 6
Application for
Continuation Membership
Name(s) of beneficiary/beneficiaries injured at the accident
Contact details of Attorney handling the claim
Short description of injuries
Relationship to principal member, e.g. mother/spouse
Date(s) of consultation/treatment
RAF Reference Number
03/08
Medical History and General Health (Continued)
5. Has your weight or the weight of any of your dependants changed by more than
5kg over the last 12 months?
6. Do you or any of your dependants experience any other ailment or disease at present?
7. Are there, in respect of you or your dependants, any other circumstances not mentioned
elsewhere in this declaration/questionnaire relating to past or present diseases, accidents,
operations or condition (is your dependent currently pregnant) for which advice has
been sought or treatment has been received or recommended during the past 12 months?
8. Are you or any of your dependants expecting to undergo any medical procedure,
is your dependent currently pregnant or expecting to receive any major dental
treatment during the next 12 months?
If you have answered “YES” to any of the preceding questions, please complete details in the following section in full:
Should you require more than 3 responses kindly complete on a seperate page and attach to this application form.
Motor Vehicle Accidents (If Applicable)
Have you or any of your dependants instituted a Road Accident Fund (RAF) claim or are you or any of your
dependants planning to instituted a such a claim in the immedaite future?
YES NO
YES NO
YES NO
YES NO
Question
Name of person suering
from illness/condition
Date on which illness/
condition began
If hospitalised, when and
for how many days
Details of operations
previously performed
Name of attending
medical practictioner
Date of last occurrence
Type of illness/condition
Question number Question number Question number
Date of Accident
D D M M Y Y Y Y
Healthy members for a safer South Africa
Page 4 of 6
Application for
Continuation Membership
03/08
Name(s) of beneficiary/beneficiaries injured on duty
Contact details of Employer handling the claim
Short description of injuries
Date(s) of consultation/treatment
IOD/Compensation Commissioner’s Reference number
Injury on Duty (IOD) (If Applicable)
Have you or any of your dependants instituted an Injury on Duty (IOD) claim or are you or any of your
dependants planning to institute such a claim in the immediate claim?
Date of injury
D D M M Y Y Y
Healthy members for a safer South Africa
1. Firstly, sharing your personal health information electronically with your medical scheme and healthcare
providers supports them in making better treatment decisions by having your detailed clinical history
on hand. It avoids repetition of tests or treatment being prescribed when these have already been tried.
Do you understand and agree to share your membership’s information electronically to improve the
quality of the healthcare you receive?
YES NO
2. Your medical scheme complies with national and international laws about storing and sharing your
information in a safe, secure, electronic environment. Do you understand and agree that we will only
provide access to authorised users? Cross-border storage is standard practice in countries with advanced
standards of healthcare. This also complies with the Protection of Personal Information Act.
YES NO
3. You can withdraw consent to share your personal healthcare information at any time. Do you understand
and agree that you will be able to do this by calling the Client Service Call Centre and making this request?
YES NO
4. If you don’t agree to share your personal health information, do you understand and agree that your health
information will not be shared unless you provide this consent? Your current medical benefits will however
not be aected.
YES NO
POPI CONSENT
Page 5 of 6
Application for
Continuation Membership
03/08
Page 6 of 6
Healthy members for a safer South Africa
Consent & Declaration
My dependant(s) and I hereby give permission for the medical practitioner and/or sta member of the
hospital in whose care I am/my dependant(s) are to supply.
i. Any information that POLMED and/or its service providers need in order to settle any claim submitted
by me or my dependant(s) to POLMED and/or its service providers:
ii. POLMED and/or its service provider in the event of hospitalisation with any information the case
manager needs in order to manage my case or that of my dependant(s);
iii. The healthcare management with any information, on an anonymous and untraceable basis, that is
required for administrative and statistical purposes.
It is important to give POLMED and/or its contracted service provider your consent to negotiate with your
doctor(s), hospital or any other healthcare provider in order to ensure that you receive optimal care.
I declare that:
i. The content of this form is true, correct and complete;
ii. I am aware that as per rule 16.2.1 I can only change my benefit plan at the end of each year to take
eect on 1 January of the following year;
iii. The mentioned particulars concerning my dependant(s) and me are correct and I/he/she/they qualify/ies
for admission as beneficiaries in terms of the rules of the Scheme; and
iv. my mentioned dependant(s) are fully dependent on me.
I, and my dependant(s), shall adhere to POLMED rules. I herewith irreversibly authorise POLMED to recover
from my bank account any contributions I may legally owe POLMED.
Signature of
Principal member or
Guardian (if orphaned)
Date
D D M M Y Y Y Y
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Application for Continuation Membership (Law for All South Africa)

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Completed 31 October 2021

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