Fillable Applying to become a member of TFG Medical (Law for All South Africa)

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Applying to become a member of TFG Medical (Law for All South Africa)

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Contact details
Tel:0860123077•POBox652509,Benmore2010•www.tfgmedicalaidscheme.co.za
Applying to become a member of TFG Medical Aid Scheme in 2022 (with underwriting)
For TFG office use
Employeenumber
Costcentrecode
Branchcode
ThankyoufordecidingtoapplytojoinTFGMedicalAidScheme.Thisdocumentisanapplicationformformembership.
Italsocontainstermsandconditionsformembership.Pleasemakesureyoureadandunderstandtheserules.
Who we are
TFGMedicalAidScheme(referredtoas‘theScheme’),registrationnumber1578,isthemedicalschemethatyouareapplyingtobecomea
memberof.Thisisanon-profitorganisation,registeredwiththeCouncilforMedicalSchemes.
DiscoveryHealth(Pty)Ltd(referredtoas‘theadministrator’)isaseparatecompanyandanauthorisedfinancialservicesprovider(registration
number1997/013480/07).WetakecareoftheadministrationofyourmembershipfortheScheme.
How to complete this form
Please go through these steps:
1. Pleaseuseoneletterperblock,completeinblackinkandprintclearly.
2. Readandunderstandthetermsandconditionsformembership(section10).
3. Signsections6,9and10.
4. Pleasemakesurethemainapplicantsignsanddatesanychanges.
5. PleasereturnthecompletedandsignedformtothePayrollDepartment,TFGHeadOffice,Parow.
6. Provisionismadeinthisformforyouandyourdependantstoprovideinformationrelatingtoyourrace.Thisinformationisrequiredbythe
CouncilforMedicalSchemeforstatisticalpurposesonly.Youarenotcompelledtoprovidethisinformation.
7. Pleaseattachacopyofeachapplicant’sidentitydocumenttothisapplicationform.Wealsoacceptvalidpassportsandbirthcertificatesfor
children.
Once you send us your application form, here is what will happen:
Ifanydetailsaremissingorifweneedmoreinformationforunderwritingpurposes,wewillcontactyou.
Wewillactivateyourmembershipandsendyouoryouremployeraletterofconfirmationwhenweareofferingstandardtermsofacceptance
(nowaitingperiodsorlate-joinerpenalties).Foranynon-standardterms,wewillissueacounter-offerletterwhichwillindicateanyconditions
applicabletoyourmembership(waitingperiodsand/orlate-joinerpenalties).Youmayaccepttheofferbysigningandreturningthisletterfor
ustoactivateyourmembership.
Wewillsendyouoryouremployer,thecounterofferletterandanyoutstandingunderwritingrequirementswherewecannotofferstandard
termsofacceptanceforbothyouandyourdependant/s(adultandchilddependant/s).
Wewillsendyouoryouremployerawelcomeletter,SMSoranemailtoletyouknowwhenyourapplicationisconsideredtohavebeenfully
andcompletelymade.Thisdatemaydifferfromthedateonwhichyousigntheapplicationform.
Youwillthengetapackinthepost.
Ifyoudonothearfromussevendaysaftersendingusyourapplicationform,pleasecontactuson0860 100 345oryouremployercontact
person.
Ifyouhaveanyquestions,pleaseletusknow.Oncewehaveassessedyourapplication,wewillletyouknowwhatwillhappennext.
Whenyousignthisapplication,youconfirmthatyouhavereadandunderstoodthetermsandconditions(section10ofthisform)for
membershipandagreetothem.
1. About Yourself (main applicant)
Coverstartdate
Title
Initials
Surname
Firstname/s(asperidentitydocument)
Preferredname
Gender M F
D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 1 of 14
06.01.2022
Race African Coloured Indian/Asian White Other
You are not compelled to provide this information. The scheme is required by the Council for Medical Schemes to collect this data and it will be
used for statistical purposes.
Donotwanttodisclose
Dateofbirth
Previousormaidenname
Preferredcommunication: Email Post
Bychoosingemail,youwillreceiveyourcommunicationquickerandthereislessofanimpactontheenvironment.
Preferredlanguage: English Afrikaans
Occupation
Taxnumber
IDorpassportnumber
Countryofissue
Telephone(H)
Work
Cellphone
Fax
Emailaddress
Postal address (post collected from post box, suite or private bag)
Suite PostnetSuite
Number
POBox Privatebag
Boxnumber
Suburb
Postalcode
Ifyourpostisdeliveredtoyourstreetaddress,pleasecompletethesedetailsunderphysicaladdress.
Physical address:
Suiteorunitnumber
Complexname
Streetnumber
Streetname
Suburb
Postalcode
2. About your spouse or partner (if applying for cover)
Title
Initials
Surname
Firstname(s)(asperidentitydocument)
Preferredname
Gender M F
Race African Coloured Indian/Asian White Other
You are not compelled to provide this information. The scheme is required by the Council for Medical Schemes to collect this data and it will be
used for statistical purposes.
Donotwanttodisclose

Dateofbirth
Previousormaidenname
IDorpassportnumber
Countryofissue
Telephone(H)
(W)
Cellphone
Taxnumber
Email
Partnership declaration
Ifyouarenotlegallymarriedandunabletoproduceamarriagecertificate,youmustcompletethesectionbelowinfull.Weherebydeclarethat
weareinalong-term,committedrelationshipthatislikeamarriageandthatweresidetogetheratthesameresidence.Weunderstandthatby
signingthisdeclarationweagreetoinformtheSchemeofanychangetothestatusofourrelationshiporanychangetoourlivingarrangements,
suchasseparation.Wefurtherunderstandthatiftheinformationwegiveaboutourrelationshiporresidencyisfalseinanyway,theScheme
reservestherighttoendbothourmemberships.Ifbothpartieshavenotsignedanddatedthebelowsection,wewillhalttheprocessuntilwe
receivethesectionsignedanddatedbybothparties.
D D M M Y Y Y Y
D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 2 of 14
06.01.2022
Signatureofmainapplicant
Originalhandsignaturerequired
Date
Signatureofpartner
Originalhandsignaturerequired
Date
3. About your dependant/s (if applying for cover)
Dependant 1
Title
Initials
Surname
Firstname/s(asperidentitydocument)
Preferredname
Gender M F
Race African Coloured Indian/Asian White Other
You are not compelled to provide this information. The scheme is required by the Council for Medical Schemes to collect this data and it will be
used for statistical purposes.
Donotwanttodisclose
Dateofbirth
IDorpassportnumber
Countryofissue
Pleaseanswerallquestions.
Isyourdependant:
Yourchild? Yes No
*Astudent Yes No
*Disabled? Yes No
*Aspecialdependant? Yes No
Whatisyourdependant’smaritalstatus?
Ifyourdependantisnoneoftheabove,pleaseexplainhisorherrelationshiptoyou(forexample:nephew,niece):
Doesyourdependantearnanincome? Yes No
Howmuchdoesyourdependantearneachmonth? R .
Dependant 2
Title
Initials
Surname
Firstnames
Preferredname
Gender M F
Race African Coloured Indian/Asian White Other
You are not compelled to provide this information. The scheme is required by the Council for Medical Schemes to collect this data and it will be
used for statistical purposes.
Donotwanttodisclose
Dateofbirth
IDorpassportnumber
Countryofissue
Pleaseanswerallquestions.
Isyourdependant:
Yourchild? Yes No
*Astudent? Yes No
*Disabled? Yes No
*Aspecialdependant? Yes No
Whatisyourdependant’smaritalstatus?
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 3 of 14
06.01.2022
Ifyourdependantisnoneoftheabove,pleaseexplainhisorherrelationshiptoyou(forexample:nephew,niece):
Doesyourdependantearnanincome? Yes No
Howmuchdoesyourdependantearneachmonth? R .
Dependent 3
Title
Initials
Surname
Firstname/s(asperidentitydocument)
Preferredname
Gender M F
Race African Coloured Indian/Asian White Other
You are not compelled to provide this information. The scheme is required by the Council for Medical Schemes to collect this data and it will be
used for statistical purposes.
Donotwanttodisclose
Dateofbirth
IDorpassportnumber
Countryofissue
Pleaseanswerallquestions.
Isyourdependant:
Yourchild? Yes No
*Astudent? Yes No
*Disabled? Yes No
*Aspecialdependant? Yes No
Whatisyourdependant’smaritalstatus?
Ifyourdependantisnoneoftheabove,pleaseexplainhisorherrelationshiptoyou(forexample:nephew,niece):
Doesyourdependantearnanincome? Yes No
Howmuchdoesyourdependantearneachmonth? R .
*Ifyourdependantisastudentoradisabledchild,pleasesendusthefollowing:
Ifstudent,proofofenrolmentatanacademicinstitution
Ifdisabled,yourmedicalproofofdisability
Ifspecialdependant,pleaseprovideproofoffinancialdependence.Anaffidavitisrequiredfromthemainmemberconfirmingfinancial
dependence,aswellasproofofyourdependant’sincome.Pleasealsoprovideproofthatthedependantresidesatthesameresidenceasthe
mainmember.
4. Please select your health plan
TFGHealth TFGHealthPlus
Youhavetherighttoaskforhelpinselectingahealthplanthatsuitsyourneeds.Bysigningthisapplication,youconfirmthatyouarefamiliar
withtheconditionsandbenefitsoftheplanyouselect.
Yourgrossmonthlysalary? R .
Yourspouse’sgrossmonthlysalary? R .
*Pleaseattachyourspouse’spayslipasproofofincome.Ifyourspouseisunemployed,pleaseattachanaffidavittothiseffect.
Incomeverificationmaybeconductedtodeterminewhetheryouareregisteredonthecorrectincomeband.Incomeisconsideredas:Thehigher
ofthemainmemberorregisteredspouseorpartner’searnings,commissionandrewardsfromemployment;interestfrominvestments;income
fromleasingofassetsorproperty;distributionsreceivedfromatrust,pensionand/orprovidentfund;receiptofanyfinancialassistancereceived
fromanystatutorysocialassistanceprogramme.
Choosing you and your dependant/s healthcare professional
IfyouhaveselectedTFGHealth,youneedtochooseaGPfromtheKeyCareNetworkforyouandyourdependant/s.Pleasefillinthedetailsof
theGPyouhavechosenforyouandyourdependant/s.
*Ifyoulivefarawayfromwhereyouworkoryouoftenneedtoworkindifferenttownsorprovinces,youandyourdependant/smayneeda
secondGP.
D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 4 of 14
06.01.2022
Name GP name Practice number Second GP
name*
Practice number
Mainapplicant
Spouseor
partner
Dependant1**
Dependant2**
Dependant3**
5. Employment details (to be completed by TFG Payroll only)
Nameofemployer THE FOSCHINI GROUP
Employernumber 3 7 1 6 9 3 8
Employeenumber
Dateofemployment
Branchnumber
Branchname
Costcentrenumber
Dateofpromotion(ifapplicable)
Employer warranty
1. Wewarrantthatthemainapplicantdetailedinsection1isanemployeeofourorganisation.
2. TFGMedicalAidSchememaybillusfortheamountdueforthismemberinthesamewayasitdoesforourotheremployeeswithTFG
MedicalAidScheme.
Authorisedsignatory
Originalhandsignaturerequired
Name
Designation
If you have more than three dependants, please complete an application to add dependants to TFG Medical Aid Scheme.
6. Your claims refund banking details
Please give us the details you would like us to use to refund your claims. Please note: We cannot accept credit card account
details. If we are paying a third party bank account, the main member must insert the ID number of the third party.
Bankname
Branchname
Branchcode - - -
Accountnumber
Typeofaccount Cheque Savings
Accountholder
If we are paying a third party bank account, the main member must insert the ID number of the third party.
Ifthirdpartybankdetails,pleaseinsertthethirdpartyIDnumber
AfterthirdpartyIDnumber,pleaseinsertthefollowing:Ifthethirdpartybankaccountisajointaccount,companyaccountortrustaccount
pleaseprovideproofofbankaccount.RefertoAnnexureAatthebackoftheapplicationformfortheproofofbankaccountrequired.
Bysigningthisapplication,youagreethatonceclaimshavebeenrefundedintothebankaccountyouhavechosen,theTFGMedicalAid
Schemewillnotberesponsibleinanywayfortheamountsrefunded.Pleasemakesurethatwehaveyourcorrectbankaccountdetails.
Signatureofaccountholder
Originalhandsignaturerequired
D D M M Y Y Y Y
D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 5 of 14
06.01.2022
7. Previous medical scheme details
PleasegiveusthedetailsofallregisteredSouthAfricanmedicalschemethatyoupreviouslybelongedto.Wewillusethisinformationto
determineifweneedtoapplyanylate-joinerpenaltyfee.Pleasegiveusproofintheformofamembershipcertificate.
Main applicant
Name Scheme name Start date Are you still a
member
End date if you have already
registered
Reason for leaving
Yes No
Yes No
Yes No
Yes No
If all dependants were on the same medical scheme/s as completed above, please tick here to confirm this
If any of your dependants applying for cover belonged to different medical schemes, please complete below:
Dependant
name
Scheme name Start date Are you still a
member
End date if you have already
registered
Reason for leaving
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
8. Your health questions
A.Onlythemainapplicant,spouseorpartnerandanyadultdependantapplyingforcoverneedstocompletesection8.A.
Have you or any dependant/s in this application ever experienced, been treated for, or are you currently suffering from any of the
following symptoms, conditions or disorders? We have listed some examples of conditions, symptoms or disorders under each
question. These are only examples and not the full list of conditions, symptoms or disorders. Please include congenital
abnormalities.
Please take note that if you have any symptom or condition not listed in the questions below, you should highlight and provide full
details of this symptom or condition in response to question 8.18 below. Indication of existing medical conditions on this application
does not automatically enroll you/your dependants onto the Scheme’s Disease Management programme. For more information
with regards to the Schemes disease management enrollment visit www.tfgmedicalaidscheme.co.za
8.1 Tumours, growth and disorders of the skin Yes No
Example:abnormalpapsmearresults,skinlesions,eczema,psoriasisbreastdisease,non-canceroustumours,canceroustumours,
cancerofanyorgan,fibrocysticbreastdisease,fibroadenoma,lumpinbreast,abscess,abnormalmammogramresult,abnormalPSA
(ProstateSpecificAntigen)result,anyautoimmuneconditions,anycongenitalconditionsorotherskinconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 6 of 14
06.01.2022
8.2 Heart and circulation conditions Yes No
Example:chestpain,palpitations,shortnessofbreath,coronaryheartdisease,angina,heartattack,arrhythmia,highbloodpressure
(hypertension),cardiomyopathy,valvularheartdiseaseorheartvalvereplacement,rheumaticfever,highcholesterol,previousheart
surgery,stents,pacemaker,anyautoimmuneconditions,anycongenitalconditionsandperipheralvasculardisease.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication used
for this
condition and
dosage
Date of last treatment
8.3 Gynaecological and obstetrics conditions Yes No
Example:abnormalpapsmearresults,abnormalmenstrualbleeding,endometriosis,miscarriage,polycysticovariansyndrome,infertility,
ectopicpregnancy,missedperiods,ovariancyst,anyautoimmuneconditions,anycongenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.4 Are you or any of your dependants pregnant or undergoing treatment/investigation for pregnancy? Yes No
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.5 Mental health conditions Yes No
Example:mooddisorders(depression,bipolardisorder),anxietydisorders,schizophrenia,personalitydisorders,sleepingdisorders(like
narcolepsy),eatingdisorders,Alzheimer’sdisease,dementia,attentiondeficit-hyperactivitydisorder,drugand/oralcoholabuseor
rehabilitation,suicideattempt,posttraumaticdisorders,counselling,anyautoimmuneconditions,anycongenitalconditionsandanyother
psychologicalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.6 Metabolic or endocrine conditions Yes No
Example:diabetesmellitus(highbloodsugar),diabetesinsipidus,thyroiddisease,Addison’sdisease,Cushing’ssyndrome,metabolic
syndrome,parathyroiddisease,Paget’sdisease,osteoporosis,growthdeficiency,metabolicdisorders,Conn’ssyndrome,anyautoimmune
conditions,anycongenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 7 of 14
06.01.2022
8.7. Abdominal conditions Yes No
Example:hepatitis,cirrhosis,portalhypertension,liverdisease,liverfailure,pancreatitis,cysticfibrosis,gallbladder,stones,GORD
(reflux),heartburn,oesophagealdisease,constipation,hernias,gastritis,ulcers,malabsorption,Crohn'sdisease,ulcerativecolitis,
diverticulitis,anyautoimmuneconditions,anycongenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.8 Brain and nerve conditions Yes No
Example:stroke,epilepsy,seizures,multiplesclerosis,motorneurondisease,myastheniagravis,migraine,cerebralpalsy,parkinson’s
disease,paraplegia,hemiplegia,quadriplegia,spinalcordinjury,hydrocephalus,brainshunt(VPshuntusedtodrainfluidfromthebrain),
intellectualdisability,CVA,bleedingonthebrain,down’ssyndrome,anyautoimmuneconditions,anycongenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.9 Breathing and respiratory conditions Yes No
Example:asthma,chronicobstructivepulmonarydisease,bronchiectasis,tuberculosis,bronchitisoremphysema,cysticfibrosis,
sarcoidosis,pneumonia,anyautoimmuneconditions,interstitiallungdiseasechroniccough>3monthsanycongenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.10 Musculoskeletal (back, bone and muscle pain) Yes No
Example:arthritis(anyform),ongoingjointormuscularpain,ankylosingspondylitis,degenerativediscdisease,scoliosis,kyphosis,spinal
stenosis,gout,injury,physicaldisability,prosthesis,amputation,anyautoimmuneconditions,anycongenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medicine
used for
this
condition
and dosage
Date of last treatment
8.11 Kidney or urinary conditions including current or past dialysis Yes No
Example:kidneyand/orrenalfailure,kidneystones,recurrenturinaryinfections,glomerulonephritis,nephroticsyndrome,polycystickidney
disease,urinaryincontinence,neurogenicbladder,bladderinfections,otherbladderorkidneyproblems,anyautoimmuneconditions,any
congenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 8 of 14
06.01.2022
8.12 Blood conditions
Yes No
Example:deepveinthrombosis,anaemia,polycythaemiavera,bloodclottingdiseases,leukaemia,lymphoma,pulmonaryembolus,
haemophilia,haemochromatosisandotherbleedingdisorders,anyautoimmuneconditions,anycongenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.13 Eye conditions Yes No
Example:cataract,keratoconus(crosslinkage),cornealulcer,uveitis,glaucoma,squint,ptosis,retinopathy,maculardegeneration,cornea
transplant,eyesurgery,blurredvision,eyeinfections,blindness(partialorfull),retinaldetachment,anyautoimmuneconditions,any
congenitalconditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.14 Ear, nose and throat (ENT) and dentistry conditions Yes No
Example:otitismedia(middleearinfection),otitisexterna(earcanalinfection),hearingproblems,hearingaid,cochlearimplant,tonsillitis,
adenoiditis,vertigo,deafness,sinusproblem,nasalsurgery,dentaltreatmentordentalsurgery,anyautoimmuneconditions,anycongenital
conditions.
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.15 Male urogenital conditions Yes No
Example:prostatedisorders,urogenitaldefects,varicocele,undescendedtestes,phimosis,urinaryincontinence,retention,infertility,any
autoimmuneconditions,anycongenitalconditions.
Patient
name
Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication used
for this condition
and dosage
Date of last treatment
8.16 Are any of your dependants expecting surgery or planning hospitalisation or treatment in the next 12
months or have they been admitted to hospital in the last 12 months?
Yes No
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
8.17 Have any of your dependant/s received medical advice or treatment for symptoms not diagnosed by a
medical professional, in the last 12 months before this application?
Yes No
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 9 of 14
06.01.2022
8.18 Have any of your dependants been diagnosed with or received treatment for, any condition not mentioned
in the questions above, in the last 12 months before this application?
Yes No
Patient
name
Symptoms/Medical
diagnosis
Date first
diagnosed/symptoms
Date of last symptoms,
consultations and/or
hospitalisation
Medication
used for this
condition
and dosage
Date of last treatment
HIV and AIDS
YoudonotneedtodisclosetheHIVstatusofyouoryourdependant/sonthisformifyoudonotfeelcomfortabledoingso.However,ifyouor
oneormoreofyourdependantsareHIV-positive,youortheymustcalluson0860123077withinsevenworkingdaysfromthedate
weactivateyourTFGMedicalAidSchememembership.Wetreatthisinformationinthestrictestconfidence.Ifyou,oroneormoreof
yourdependantsareHIV-positive,itisinyourinteresttoregisterontheHIVCareProgramme.A12-monthcondition-specificwaitingperiod
mayapplytothisconditionandanyrelatedconditions.IfyoudonotletusknowaboutyourHIVstatuswithin7daysofyourmembershipbeing
active,wemayendyourTFGMedicalAidscheme.
9. Privacy Statement for TFG Medical Aid Scheme administered by Discovery Health (Pty) Ltd
Privacy Statement
ThepurposeofthisPrivacyStatementistosetouthowWecollect,use,shareandotherwiseProcessYourPersonalInformation,inlinewith
theProtectionofPersonalInformationAct4of2013.
Definitions
AdministratorreferstoDiscoveryHealth(Pty)Ltd,registrationnumber1997/013480/07,anauthorisedfinancialservicesprovider,the
administratorandmanagedcareorganisationforTFGMedicalAidSchemeandasubsidiaryoftheDiscoveryGroup.
Competent Personmeansanyonewhoislegallycompetenttoconsenttoanyactionordecisionbeingtakenonanymatterconcerninga
memberordependant,forexampleaparentorlegalguardian.
Discovery GroupreferstoDiscoveryLimited,registrationnumber1999/007789/06,includingallsubsidiariesofthegroupasdefinedinthe
CompaniesAct,2008.
Personal InformationreferstopersonalinformationaboutYou.ItcanincludeinformationaboutYourtitleandname,health,financialstatus
and/orbankinginformation,maritalstatus,gender,age,ethnicgroup,nationality,language,contactnumbersoremailaddressesandpostal
and/orstreetaddressesoranyotherformofpersonalinformationasdefinedintheProtectionofPersonalInformationAct4of2013,which
TFGMASortheAdministratormayreasonablyrequiretoofferorrenderitsservices/productstoYou(totheextentthatTFGMASorthe
AdministratorispermittedinlawtodosoandwhereYouhavenotobjectedthereto).
Process(ing)referstotheautomatedormanualactivityofcollecting,recording,organising,storing,updating,distributingandremovingor
deletingPersonalInformation.
The Scheme or TFGMASreferstoTFGMedicalAidScheme,registrationnumber1578,registeredwiththeCouncilforMedicalSchemes.
Us, We or OurreferstotheSchemeandtheAdministratorjointly.
You, Yourself and Yourreferstoyou,theTFGMASmember,andincludesYourregisteredspouseand/ordependants(ifany)onYourTFGMAS
plan.
1. WhenYouapplytobecomeamemberofTFGMASandwhenYouengagewithUsfromtimetotime,YouchoosetoprovideUswithPersonal
Information.WearecommittedtotakingallreasonablestepstoprotectYourrighttoprivacyandYourPersonalInformationthatYouprovideto
Us.
2. YouhavetherighttoobjecttotheProcessingofYourPersonalInformationandYouhaveachoicewhetherornottoacceptthetermsand
conditionscontainedinthisPrivacyStatement,however,itisimportanttonotethatWerequireYouracceptanceofthesetermsand
conditionsinordertoactivateand/orserviceYourTFGMASmembership.
3. WewilltakeallreasonablestepstokeepYourPersonalInformationconfidential.Wehavephysical,technologicalandproceduralsecurity
safeguardsinplaceandwilluseOurbestendeavourstoprotectYourPersonalInformation.
4. YoumayhavegivenusthisinformationYourself,orWemayhavecollecteditfromothersources(‘Sources”)withwhomYouhavesharedYour
PersonalInformation.YouindemnifyUsagainstanylossesYoumaysustainasaresultofSourcesnotprotectingYourPersonalInformation.
5. YouunderstandthatwhenYouincludeYourspouseand/ordependentsonYourapplication,WewillProcesstheirPersonalInformationin
accordancewiththisPrivacyStatement.YouwarrantthatwhenYougiveUsPersonalInformationaboutYourspouseand/ordependants,You
havereceivedtheirpermissiontosharetheirPersonalInformationwithUsforthepurposessetoutinthisPrivacyStatement.Youindemnify
UsagainstanyclaimsresultingfromthesharingofYourspouseand/ordependents’PersonalInformationwithoutYourspouseand/or
dependents’consent.
6. IfYouaregivingconsentforapersonunder18(a“Minor”),YouconfirmthatYouareaCompetentPersoninrelationtosaidMinor.
7. YouagreethatWemayProcessYourPersonalInformationforthefollowingpurposes:
fortheadministrationofYourTFGMAShealthplan;
toprovideYouwithmanagedcareservicesonYourTFGMAShealthplan;
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 10 of 14
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toshareYourPersonalInformationwithexternalhealthspecialiststoenablethemtoassessorevaluatecertainclinicalinformationin
theeventthatYouaresubjecttosuchaclinicalassessmentunderYourTFGMAShealthplan;
tocomplywithSouthAfricanstatutoryreportingobligations;and
anyotherreasonablyrequiredpurposerelatingtotheadministrationofYourchosenTFGMAShealthplanand/orYourapplicationtojoin
TFGMAS.
Examplesoftheabovepurposesmayinclude,butarenotlimitedto:
Obtaininginformationfrom,andsharinginformationwith,YouremployerthatisrelevanttoYourapplicationformembershipwithdue
regardforconsiderationsofconfidentialityinrespectofYourhealthstatus;
CommunicatingwithYouaboutanychangesinYourTFGMAShealthplan,includingchangestoYourcontributionsorchangestothe
benefitsYouareentitledtoontheTFGMAShealthplanYouhavechosen;and
TransferringYourPersonalInformationoutsidethebordersoftheRepublicofSouthAfricainordertogiveeffecttoYourTFGMAShealth
plan,orifYouprovideanemailaddresswhichishostedoutsidethebordersoftheRepublicofSouthAfrica.
8. YouagreethatWemayshareYourPersonalInformationwithathirdpartycontractedtoUswhorequiresYourPersonalInformationtoprovide
ahealthcareservicetoYouintermsofYourTFGMAShealthplan.WewillonlyshareYourPersonalInformationwithathirdpartyif:
YouhavegivenYourconsentforthedisclosureofYourPersonalInformationtothatthirdparty;or
WehavealegalorcontractualdutytogiveYourPersonalInformationtothatthirdparty,or
Weneedtoshareitwiththemforriskanalysisorfrauddetection,preventionorrecoverypurposes.
WewillensurethatanyonewithwhomWeshareYourPersonalInformationonthetermsincludedinthisPrivacyStatementagreestotreat
YourPersonalInformationwiththesamelevelofprotectionasWeareobligedto.
9. YouagreethatwemayprovideYourPersonalInformationtoanyotherentitywithintheDiscoveryGroupwithwhichYouhaveappliedfora
product,serviceorbenefitandwheresuchapplicationincludesYourexpressconsentforsaidentitywithintheDiscoveryGrouptorequest
YourPersonalInformationfromUs,andforUstoreleaseYourPersonalInformationtosaidentity.
10. YouagreethatWemayshareYourPersonalInformationwiththirdpartieswithwhomWehavecontracted,suchasacademicsand
researchers,whoseresearchisrequiredtoevaluateOurservicetoYou.WewillensurethatPersonalInformationaboutYouthatisshared
withsuchthirdpartieswillbemadeanonymoustotheextentpossible.IfWepublishtheresultsofanyacademicresearch,Youwillnotbe
identifiedbynameinanysuchpublication.
11. ByacceptingthisPrivacyStatement,YouauthoriseUstoobtainandsharePersonalInformationaboutYourcreditworthinesswithanycredit
bureauorcreditproviders’industryassociationorindustrybody.ThisincludesPersonalInformationaboutcredithistory,financialhistory,
judgments,anddefaulthistory.ItalsoincludessharingofPersonalInformationforpurposesofriskanalysisandtracing.
12. YouagreethatWemaycommunicatewithYouelectronicallyaboutanychangestoYourTFGMAShealthplan,includingchangestoYour
contributionsorchangestothebenefitsYouareentitledtoontheTFGMAShealthplanYouhavechosen.
13. YouagreethatwemayprocessYourinformationusingautomatedmeans(withouthumaninterventioninthedecisionmakingprocess)to
makeadecisionaboutYouorYourapplicationforanyproductorservice.YoumayqueryadecisionmadeaboutYoubysendingYourquery
toPrivacy@discovery.co.za.
14. TheSchemehasadutytokeepYouupdatedaboutanyoffersrelevanttoYouthataremadeavailablefromtimetotime.Youagreethatthe
SchememaycommunicatewithYouinthisregard.
15. YoumayinformtheAdministratorifYouwishtoreceiveanydirecttelephonicmarketingabouttheAdministrator’sproductsandservices.
16. YouhavetherighttoknowwhatPersonalInformationWeholdaboutYou.IfYouwishtoreceivecopiesofdocumentscontainingYour
PersonalInformation,pleasecompletean‘AccessRequestForm’,attachedtothePAIAmanual,onwww.tfgmedicalaidscheme.co.za.We
areentitledtochargeareasonablefeeforthisserviceandWewillletYouknowwhatthefeeisatthetimeofYourrequest.
17. YouagreethatWemaykeepYourPersonalInformationuntilYouaskUstodeleteand/ordestroyit,unlessthelawrequiresUstokeepit.
YouhavetherighttoaskUstoupdateoramendYourPersonalInformation
18. IftheSchemeorAdministratorbecomesinvolvedinaproposedoractualamalgamationormerger,acquisitionoranyformofsaleofany
assets,WemayshareYourPersonalInformationwiththirdpartiesinconnectionwiththetransaction.Inthecaseofsuchanevent,thenew
entitywillhaveaccesstoYourPersonalInformation.ThetermsofthisPrivacyStatementwillcontinuetoapply.
19. WemaychangethisPrivacyStatementfromtimetotime.Thecurrentversionisavailableonwww.tfgmedicalaidscheme.co.za
20. IfYoubelievethattheSchemeorAdministratorhaveusedYourPersonalInformationcontrarytothisPrivacyStatement,Werequestthat
YoufirstfollowOurinternalcomplaintsproceduretoresolvethecomplaint.Weexplainthecomplaintsanddisputesprocessonthewebsite
www.tfgmedicalaidscheme.co.za.IfYouarenotsatisfiedwiththeoutcomeofYourcomplaint,YouhavetherighttolodgeYourcomplaint
withtheInformationRegulator,undertheProtectionofPersonalInformationAct4of2013.
21. ContactdetailsfortheInformationRegulatorare:
TheInformationRegulator(SouthAfrica)
JDHouse
27StiemensStreet
Braamfontein
2001
POPIAComplaints@inforegulator.org.zaorPAIAComplaints@inforegulator.org.za
Signature of Main Member
By signing this Privacy Statement, You acknowledge that You have read, understood and accepted all the terms and
conditions contained in this Privacy Statement.
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 11 of 14
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10. Terms and conditions applicable to TFG Medical Aid Scheme ("TFGMAS")
1. Who “we” are
TFGMAS,registrationno1578,registeredwiththeCouncilforMedicalSchemes.DiscoveryHealth(Pty)Ltd,registrationnumber
1997/013480/07,theadministratorandmanagedcareorganisationforTFGMAS,andanauthorisedfinancialservicesprovider.
2. Scheme rules for membership
TherulesofTFGMASrecordyourrightsandresponsibilitiesforyourmembershipofTFGMAS.Theymaychangefromtimetotime.Youmay
askusforacopyatanytime.Whenyousignthisapplication,youconfirmthatyouhavereadandunderstoodthetermsandconditionsand
youagreethatyouandthoseyouapplyforwillbeboundbytheseandschemerules.
3. Who you are applying for
YoumayapplytojoinTFGMASonyourownortogetherwithotherpeople–yourspouse,yourpartnerandpeoplewhoarefinancially
dependentonyouasdefinedintheTFGMASrules.Foranyonetobetreatedasfinanciallydependentforthisapplication,youmusthavea
legalresponsibilitytoprovidefinanciallyforthatdependant.Wemightaskyoutogiveusproofoffinancialorlegalresponsibility.You
maybecalledtheprincipalmemberormainmemberinourfuturecommunicationstoyou.
4. Acting for others
You confirm you have the right to act for others
Bysigningthisdocument,youconfirmthat:
youhavetherighttoapplyformembershipandtoactforthoseyouapplyforinanymatterrelatingtothisapplication;
youhavereceivedpermissionfromyourspouseandanydependant/sover18toactfortheminanymatterrelatingtothisapplication.
5. Giving and getting information
You must give true, correct and complete information
Toconsideryourapplicationformembership,TFGMASmustlearnmoreaboutyouandthoseyouapplyfor.Informationaboutyouandthose
youapplyformustbetrue,correctandcomplete.Thisincludesthedetailsyougiveinthisapplicationformandinfuturedealings
withus.Itisimportantthatyoutellusaboutanymedicalcondition,symptomorillnessrelatingtoyouorthoseyouapplyfor,evenifyou
donotconsideritrelevanttoyourapplication.Wemayaskthoseyouapplyforwhoare18andolderformoreinformationaboutthemselves.
Your legal address
Wewillsenddocumentstoyouattheaddressyouindicatedasthecommunicationchannelyouprefertobecontactedon.Ifitis
necessarytosendyouanylegalnoticesorsummonses,ourlegalteamwillservetheseatthephysicaladdressyouhavegiven,oratanyother
addressyouhavegivenus.Itisyourresponsibilitytomakesurewehavethecorrectaddressforyou.
TFGMAS and Discovery Health (Pty) Ltd may record telephone calls
Wemayrecordtelephoneconversationswithyouandwiththoseyouapplyfor.Therecordingsandallinformationwegetduringthe
recordingswillbeprocessedandkeptasrequiredbylaw.
TFGMAS and Discovery Health (Pty) Ltd may get information about you from other relevant sources
Toconsideryourapplicationformembership,conductunderwritingtoconsideraclaimformedicalexpenses,youagreethatwecanget
informationaboutyouandthoseyouapplyforfromotherrelevantsources.TheseincludeanyentitythatispartofDiscoveryLimited,medical
practitioners,creditbureausorindustryregulatorybodies.Wemay(atanytimeandonanongoingbasis)verifywiththepartiesmentionedin
thissectionthattheinformationyougiveonthisapplicationandinrespectofanymatterpertainingtoorthataroseduringyourmembershipof
TFGMAS,istrue,correctandcomplete.Yougiveyourpermissionthatwemaygetanyinformationthatisrelevanttoyourapplicationfromyour
employer.
Tell TFGMAS or Discovery Health (Pty) Ltd immediately if your information changes
Youoryouremployermusttellusinwritingifanyoftheinformationyougave,inyourapplicationformembership,changesbetweenthedayyou
signthisdocumentandthedayyourmembershipstarts.Thisincludesinformationaboutyourhealthandthehealthofthoseyouapplyfor.We
needadvancenoticeofanyadministrativechangessuchascancellationofmembership,asbackdatedchangesmaynotbe
accepted.
When TFGMAS may cancel your membership/s
TFGMASmaycancelanymembershipsimmediately,ifyouandthoseyouapplyfor:
donotgiveusinformationthatlaterturnsouttoberelevanttothisapplication;
giveusanyinformationthatisnottrue,correctandcomplete;
donottellusaboutanyrelevantchanges(includingaboutyourhealthandthehealthofthoseyouapplyfor)betweenthedayyousignthis
documentandthedaycoverstarts.
6. About becoming a member
TFGMAS might not pay for certain expenses immediately after you become a member
TFGMASmayhavewaitingperiodsthatapplyincertaincircumstances.ThismeanstheremaybeasettimeperiodbeforetheTFGMASstarts
payingclaimsforanygeneralorspecificmedicalconditions.Pleasespeaktoustofindoutifwaitingperiodsapplytoyourmembershipandthe
membershipsofthoseyouapplyfor.
Resign from current medical schemes when accepted
Itisillegaltobeamemberofmorethanonemedicalschemeatthesametime.Youandthoseyouapplyformustresignfromyourcurrent
medicalschemeswhenyoureceivenoticefromTFGMASbyletter,emailorSMStellingyouthatyouandthoseyouapplyforhavebeen
accepted.
You must ensure contributions are paid on time
AsthemainmemberofTFGMAS,youareresponsibleforensuringthatyourcontributionsandthecontributionsofthoseyouapplyforare
paidontimeeverymonthtoavoidsuspensionofbenefits.TFGMAShastherighttoamendmonthlycontributionsandbenefitsfromtime
totime.Ifyoupayyourowncontributions,youwillbeabletoidentifythedebitorderforyourmonthlycontributionsonyourbankstatement,the
referencenumberTFGCONTwillbeused.
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 12 of 14
06.01.2022
7. Repaying money owed to TFGMAS
TFGMAShastherightatanytimetocollectfromyouanyamountthatyouowetotheScheme.Wewillnotifyyouifthereisanyamountthat
youowetoTFGMAS.
Bysigningthisform,youagreethatanymoneyyouowetoTFGMASmaybedeductedfromanyfutureclaimpaymentamountsthataredueto
bepaidtoyou.YouwillbeabletoidentifythedebitorderforthemoneyowingtotheSchemeonyourbankstatement,thereferencenumber
TFGCLWBKwillbeused.
Signatureofmainmember
The main member must sign and date any changes
Please do not sign an incomplete application form
I confirm the information is accurate and complete
Date
FOR COMPANY STAMP
D D M M Y Y Y Y
Please note that this form expires on 31/03/2023. Up to date forms are available on www.tfgmedicalaidscheme.co.za.
Alternatively members can phone 0860 123 077 and health professionals can phone 0860 44 55 66.
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 13 of 14
06.01.2022
11. Banking details for a third party - Annexure A
Pleaseattachtherelevantproofofbankaccountifyougiveathirdparty’sbankaccountdetailsforclaimrefunds.
Documents we need for a third-party bank account
(Athirdpartycanbeanyone,suchasyourspouse,aunt,uncle,friend,fatherorson.)
Proofoftheaccount(bankstatementorbankletternotolderthanthreemonths)
Acopyofthethirdparty’s(accountholder)ID,passportordrivinglicence
Acopyofthemainmember’sID,passportordrivinglicence
Documents we need for a joint bank account
Proofofaccount(bankstatementorbankletternotolderthanthreemonths)
AcopyoftheID,passportordrivinglicenceofeachofthejointowners.
Documents we need for a company account
Proofofaccount(bankstatementorbankletternotolderthanthreemonths)
AcopyoftheID,passportordrivinglicenceofthepersonswhohaveauthoritytosignonbehalfofthecompany
Aletterofauthority.Thelettermust:
Statethattheaccountcanbeused
Statethemembershipdetails(includingthemembershiporpolicynumbers)forwhichthebankaccountwillbeused
Includethedetailsofthesignatory
Bedatedandsignedbyanauthorisedpersononbehalfofthecompany
Acopyofthecompany’scertificateofregistration.
Acopyofthemainmember’sID,passportordrivinglicence
Documents we need for a trust account
Proofofaccount(bankstatementorbankletternotolderthanthreemonths)
AcopyoftheID,passportordrivinglicenceofeachofthetrusteesoftheaccount
Acopyofthecertificateofregistrationofthetrust
Acopyofthetrustresolution.Theresolutionmust:
Showthetrustees
Bedatedandsignedbyanauthorisedpersononbehalfofthetrust
Containthemembershiporpolicynumbers
Acopyofthemainmember’sID,passportordrivinglicence
Ifyouarecompletingtherequestonbehalfofthemainmember,pleaseincludeproofthatyouhavethenecessaryauthoritytodoso,for
example,aletterofauthorityoraletterofexecutorship.
TFG Medical Aid Scheme is a registered medical scheme and regulated by the Council for Medical Schemes (CMS). The CMS contact details are as follows:
Email: complaints@medicalschemes.co.za | Customer Care Centre: 0861 123 267 | Website: www.medicalschemes.co.za
TFGABM001
TFG Medical Aid Scheme. Registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.
Page 14 of 14
06.01.2022
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Applying to become a member of TFG Medical (Law for All South Africa)

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