Who we are
Discovery Health Medical Scheme (referred to as 'the Scheme'), registration number 1125, is the medical scheme that you are applying to
become a member of. This is a not-for-profit organisation, registered with the Council for Medical Schemes.
Discovery Health (Pty) Ltd, registration number 1997/013480/07, (referred to as 'the administrator') is a separate company and an authorised
financial services provider and is the administrator and managed care organisation for Discovery Health Medical Scheme and takes care of the
administration of your membership.
Contact us
Tel (members): 0860 99 88 77, Tel (health partner): 0860 44 55 66, PO Box 784262, Sandton, 2146, www.discovery.co.za, 1 Discovery Place,
Sandton, 2196.
Purpose of the form
This form is to apply for out-of-hospital treatment of a Prescribed Minimum Benefit condition.
What you must do
You need to complete section 1 of this form. Fill in the form in black ink and print clearly, or complete the form digitally.
All relevant sections must be physically signed the patient and cannot be signed digitally. The main member and patient must sign and date
any changes.
Your healthcare professional must complete section 2.1, 2.2, 2.3, 2.4 and section 3 to apply for treatment for a Prescribed Minimum Benefit.
Please include detailed documentation to support your application.
Please fax this completed and signed form with any documentation to support this application to 011 539 2780 or email
PMB_APP_FORMS@discovery.co.za.
You will receive a letter informing you of our decision and the process you should follow.
1. Patient details
Title
Initials
Surname
First name(s) (as per identity document)
Preferred name
Gender F M
Date of birth - -
ID or passport number
Country of issue
Membership number
Telephone (H) -
Telephone (W) -
Cellphone -
Fax -
Email
Relationship to main member
The outcome of this application can be communicated to me by Email Fax
I give permission for my healthcare professional to provide Discovery Health Medical Scheme and Discovery Health (Pty) Ltd (as administrator)
with my diagnosis and other relevant clinical information required to review my application for Prescribed Minimum Benefits.
I understand that:
1.1. Funding from the Prescribed Minimum Benefit is subject to clinical entry criteria as determined by Discovery Health Medical Scheme.
1.2. Each case will be assessed on its own merit.
1.3. By registering for the Prescribed Minimum Benefits, I agree that my condition may be subject to disease management intervention and
periodic review and that this may include access to my medical records.
1.4. The covered Prescribed Minimum Benefit conditions and clinical entry criteria may change from time to time and I may need to send an
updated or new application form, if Discovery Health Medical Scheme asks for this.
1.5. The covered Prescribed Minimum Benefit conditions and clinical entry criteria may change from time to time and I may need to send an
Application for out-of-hospital management of a
Prescribed Minimum Benefit condition 2020
D D M M Y Y Y Y
