Who we are
Discovery Health Medical Scheme, registration number 1125, is a not-for-profit organisation registered with the Council for Medical Schemes,
and is the medical scheme that you are a member of.
Discovery Health (Pty) Ltd, registration number 1997/013480/07, 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.
Tel (members): 0860 99 88 77, Tel (health partners): 0860 44 55 66, www.discovery.co.za, PO Box 784262, Sandton, 2146,
1 Discovery Place, Sandton, 2196.
Purpose of the from
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 by 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 email the signed form with any documentation to support this application to PMB_APP_FORMS@discovery.co.za, or get help on
www.discovery.co.za under Medical Aid > Get Help > Submit a document and follow the guided steps through our Virtual Agent.
You will receive a letter informing you of our decision and the process you should follow.
1. Patient details
First name(s) (as per identity document)
Gender F M
Date of birth - -
ID or passport number
Country of issue
Telephone (H) -
Telephone (W) -
Relationship to main member
The outcome of this application will be communicated to you by email.
Member’s acceptance and permission
I give permission for my healthcare provider to provide Discovery Health Medical Scheme and the administrator with my diagnosis and other
relevant clinical information required to review my application. I agree to my information being used to develop registries. This means that you
give permission for us to collect and record information about your condition and treatment. This data will be analysed, evaluated and used to
measure clinical outcomes and make informed funding decisions.
I understand that:
1.1. Funding from the Prescribed Minimum Benefit (PMB) is subject to meeting clinical entry criteria requirements as determined by
Discovery Health Medical Scheme.
1.2. The Prescribed Minimum Benefit (PMB) provides cover for disease-modifying therapy only, which means that not all medicines for a
listed condition are automatically covered by Prescribed Minimum Benefits (PMBs).
1.3. By registering for Prescribed Minimum Benefits (PMBs), I agree that my condition may be subject to disease management interventions
and periodic review and that this may include access to my medical records.
1.4. Funding for treatment from Prescribed Minimum Benefit (PMB) will only be effective from when Discovery Health Medical Scheme
Application for out-of-hospital treatment of a
Prescribed Minimum Benefit condition 2021
D D M M Y Y Y Y