Fillable Chronic Illness Benefit Application form 2020 (Law for All South Africa)

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Chronic Illness Benefit Application form 2020 (Law for All South Africa)

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The Chronic Illness Benefit Application form 2020 (Law for All South Africa) form is 9 pages long and contains:

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Who we are
DiscoveryHealthMedicalScheme(referredtoas‘theScheme’),registrationnumber1125,isthemedicalscheme.Thisisanon-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 form
ThisapplicationformistoapplyfortheChronicIllnessBenefitandisonlyvalidfor2020.Makereferencetothefootnotethatindicatestheexpiry
dateoftheform.Downloadthelatestversionofallformsfromwww.discovery.co.za,underMedicalAid>Findadocument
How to complete this form
Fillintheforminblackinkandprintclearly,orcompletetheformdigitally.
Allrelevantsectionsmustbephysicallysignedandcannotbesigneddigitally.Thepatientmustsignanddateanychanges.
Completeandsignsection1.
Taketheapplicationformtoyourdoctortocompletesection2,otherrelevantsections,signsection13andattachanytestresults,clinical
reportsorotherinformationthatweneedtoreviewtherequest.TheserequirementsareshowninSections3and4.
Faxthecompletedapplicationformandallsupportingdocumentsto 011 539 7000,emailittoCIB_APP_FORMS@discovery.co.zaorpostit
toDiscoveryHealth,CIBDepartment,POBox652919,Benmore,2010.
1. Patient’s details
Title
Initials
Surname
Firstname(s)(asperidentitydocument)
Gender M F
Dateofbirth - -
Membershipnumber
Telephone(H) -
Telephone(W) -
Cellphone -
Fax -
Email
Theoutcomeofthisapplicationcanbecommunicatedtomeby Email Fax
IacknowledgethatIhavereadandunderstoodtheconditionsunder“Member’sacceptanceandpermission”onpage2.
Patient'ssignature(ifpatientisa
minor,mainmembertosign)
Date - -
Please only sign if information is true, complete and correct.
Chronic Illness Benefit Application form 2020
D D M M Y Y Y Y
D D M M Y Y Y Y
Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 1 of 9
11.09.2020
2. Doctor’s details
Nameandsurname
BHFPracticenumber
Speciality
Telephone -
Fax -
Email
Theoutcomeofthisapplicationcanbecommunicatedtomeby Email Fax
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:
2.1. FundingfromtheChronicIllnessBenefitissubjecttomeetingbenefitentrycriteriarequirementsasdeterminedbyDiscoveryHealthMedical
Scheme.
2.2. TheChronicIllnessBenefitprovidescoverfordisease-modifyingtherapyonly,whichmeansthatnotallmedicinesforalistedconditionare
automaticallycoveredbytheChronicIllnessBenefit.
2.3. ByregisteringfortheChronicIllnessBenefit,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.
2.4. FundingformedicinefromtheChronicIllnessBenefitwillonlybeeffectivefromwhenDiscoveryHealthMedicalSchemereceivesan
applicationformthatiscompletedinfull.PleaserefertothetableinSections3and4toseewhatadditionalinformationisrequiredtobe
submittedfortheconditionforwhichyouareapplying.
2.5. Anapplicationformneedstobecompletedwhenapplyingforanewchroniccondition.
2.6. Ifyouareapprovedonthebenefit,youneedtoletusknowwhenyourtreatingdoctorchangesyourtreatmentplansothatwecanupdate
yourchronicauthorisation/s.Youcandothisbye-mailingthenewprescriptiontousoraskingyourdoctororpharmacisttodothisforyou.
Alternatively,yourdoctorcanlogontoHealthIDtomakethechanges,providedthatyouhavegivenconsent.Ifyoudonotletusknowabout
changestoyourtreatmentplan,wemaynotpayyourclaimsfromthecorrectbenefit.
2.7. Tomakesurethatwepayyourclaimsfromthecorrectbenefit,weneedtheclaimsfromyourhealthcareproviderstobesubmittedwiththe
relevantICD-10diagnosiscode(s).PleaseaskyourdoctortoincludeyourICD-10diagnosiscode(s)ontheclaimstheysubmitandonthe
formthattheycompletewhentheyreferyoutothepathologistsand/orradiologistsfortests.Thiswillenablethepathologistsand
radiologiststoincludetherelevantICD-10diagnosiscode(s)ontheclaimstheysubmit,ensuringthatwepayyourclaimsfromthecorrect
benefit.
Consent for processing my personal information
IgivetheSchemeandtheadministratorconsenttohaveaccesstoandprocessallinformation(includinggeneral,personal,medicalorclinical
information)thatisrelevanttothisapplication.Iunderstandthatthisinformationwillbeusedforthepurposesofapplyingforandassessingmy
fundingrequestforChronicIllnessBenefits.IconsenttotheSchemeandtheadministratordisclosing,fromtimetotime,informationsuppliedto
them(includinggeneral,personal,medicalorclinicalinformation)tomyhealthcareproviderandtorelevantthirdparties,toadministerthe
ChronicIllnessBenefitsaswellasundertakemanagedcareinterventionsrelatedtothechroniccondition.
Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 2 of 9
11.09.2020
3. The Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions covered on all plans
DiscoveryHealthMedicalSchemecoversthefollowingPrescribedMinimumBenefitChronicDiseaseListconditionsinlinewithlegislation.Your
coverissubjecttobenefitentrycriteria.ApprovalontheChronicIllnessBenefitforyourPMBCDLcondition(s)offerscoverformedicineand
treatmentbasketsforthemanagementofyourcondition(s).Pleaserefertothewebsiteformoreinformationonwhatiscoveredonthebenefit
andhowitiscovered.
Chronic disease list condition Benefit entry criteria requirements
Addison’sdisease Applicationformmustbecompletedbyanendocrinologist,paediatrician(inthecaseofachild)or
specialistphysician
Asthma None
Bipolarmooddisorder Applicationformmustbecompletedbyapsychiatrist
Bronchiectasis Applicationformmustbecompletedbyapaediatrician(inthecaseofachild),pulmonologistor
specialistphysician
Cardiacfailure None
Cardiomyopathy None
Chronicobstructivepulmonarydisease
(COPD)
1. Section5ofthisapplicationformmustbecompletedbythedoctor
2. Pleaseattachalungfunctiontest(LFT)reportwhichincludestheFEV1/FVCpostbronchodilator
use
3. Pleaseprovideadditionalinformationwhenapplyingforoxygenincluding:
3.1. arterialbloodgasreportoffoxygentherapy
3.2. numberofhoursofoxygenuseperday
Chronicrenaldisease
1. Section6ofthisapplicationformmustbecompletedbythedoctor
2. Applicationformmustbecompletedbyanephrologistorspecialistphysician
3. Pleaseattachasupportinglaboratoryreportreflectingcreatinineclearance
Coronaryarterydisease None
Crohn’sdisease Applicationformmustbecompletedbyagastroenterologist,paediatrician(inthecaseofachild),
specialistphysicianorsurgeon
Diabetesinsipidus Applicationformmustbecompletedbyanendocrinologist
Diabetestype1 None
Diabetestype2
1. Section7ofthisapplicationformmustbecompletedbythedoctor
2. Pleaseattachthediagnosinglaboratoryreport
Dysrhythmia None
Epilepsy Applicationformfornewlydiagnosedpatientsmustbecompletedbyaneurologist,paediatrician(in
thecaseofachild)orspecialistphysician
Glaucoma Applicationformmustbecompletedbyanophthalmologist
Haemophilia
1. Section8ofthisapplicationformmustbecompletedbythedoctor
2. PleaseattachthediagnosinglaboratoryreportreflectingfactorVIIIorIXlevels
HIVandAIDS(antiretroviraltherapy) PleasedonotcompletethisapplicationformforcoverforHIVandAIDS.Toenrolorrequest
informationonourHIVCareprogramme,pleasecall0860100417
Hyperlipidaemia
1. Section9ofthisapplicationformmustbecompletedbythedoctor
2. Pleaseattachthediagnosinglaboratoryreport
Hypertension Section10ofthisapplicationformmustbecompletedbythedoctor
Hypothyroidism
1. Section11ofthisapplicationformmustbecompletedbythedoctor
2. Pleaseattachthediagnosinglaboratoryreport
Multiplesclerosis(MS)
1. Applicationformmustbecompletedbyaneurologist
2. Pleaseattachareportfromaneurologistforapplicationsforbetainterferonindicating:
2.1. Relapsing–remittinghistory
2.2. AllMRI
2.3. Extendeddisabilitystatusscore(EDSS)
Parkinson’sdisease Applicationformmustbecompletedbyaneurologistorspecialistphysician
Rheumatoidarthritis Applicationformmustbecompletedbyarheumatologist,paediatrician(inthecaseofachild)or
specialistphysician
Schizophrenia Applicationformmustbecompletedbyapsychiatrist
Systemiclupuserythematosus Applicationformmustbecompletedbyanephrologist,paediatrician(inthecaseofa
child),pulmonologist,rheumatologistorspecialistphysician
Ulcerativecolitis Applicationformmustbecompletedbyagastroenterologist,paediatrician(inthecaseofachild),
specialistphysicianorsurgeon
Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 3 of 9
11.09.2020
4. The Additional Disease List (ADL) conditions covered on Executive and Comprehensive Plans, except the Classic
Smart Comprehensive Plan
IfyouareonanExecutiveorComprehensivePlan,excepttheClassicSmartComprehensivePlanyouhavecoverforallthechronicconditionsin
theAdditionalDiseasesListbelow.Yourcoverissubjecttobenefitentrycriteria.ApprovalontheChronicIllnessBenefitforyourADL
condition(s)offerscoverformedicineforthemanagementofyourcondition(s).Pleaserefertothewebsiteformoreinformationonhowmedicine
iscoveredonthebenefit.
Additional disease list condition Benefit entry criteria requirements
Ankylosingspondylitis Applicationformmustbecompletedbyarheumatologistorspecialistphysician
Behcet’sdisease Applicationformmustbecompletedbyarheumatologistorspecialistphysician
Cysticfibrosis Applicationformmustbecompletedbyapaediatrician(inthecaseofachild),pulmonologist,or
specialistphysician
Delusionaldisorder* Applicationformmustbecompletedbyapsychiatrist
Dermatopolymyositis Applicationformmustbecompletedbyadermatologist,rheumatologistorspecialistphysician
Generalisedanxietydisorder* ApplicationsforfirstlinetherapywillbeacceptedfromGPsfor6monthsonly.Applicationfroma
psychiatristwillberequiredforfurthercover
Huntington’sdisease Applicationformmustbecompletedbyaneurologistorpsychiatrist
Isolatedgrowthhormonedeficiencyin
childrenunder18years
1. Applicationformmustbecompletedbyanendocrinologistorpaediatrician.
2. Pleaseattachtherelevantlaboratoryresultsandgrowthchart
Majordepression* ApplicationsforfirstlinetherapywillbeacceptedfromGPsfor6monthsonly.Applicationfroma
psychiatristwillberequiredforfurthercover
Motorneuronedisease None
Musculardystrophyandotherinherited
myopathies*
None
Myastheniagravis* None
Obsessivecompulsivedisorder Applicationformmustbecompletedbyapsychiatrist
Osteoporosis
1. Section12ofthisapplicationformmustbecompletedbythedoctor
2. Applicationformmustbecompletedbyanendocrinologistforpatients<50yearsofage
3. PleaseattachthediagnosingDEXAbonemineraldensityscan(BMD)report
Paget’sdisease Applicationformmustbecompletedbyapaediatrician(inthecaseofachild)orspecialist
physician
Panicdisorder ApplicationsforfirstlinetherapywillbeacceptedfromGPsfor6monthsonly.Applicationfroma
psychiatristwillberequiredforfurthercover
Polyarteritisnodosa Applicationformmustbecompletedbyarheumatologist
Post-traumaticstressdisorder* Applicationformmustbecompletedbyapsychiatrist
Psoriaticarthritis Applicationformmustbecompletedbyarheumatologistorspecialistphysician
Pulmonaryinterstitialfibrosis Applicationformmustbecompletedbyapaediatrician(inthecaseofachild),pulmonologistor
specialistphysician
Sjogren’ssyndrome Applicationformmustbecompletedbyanephrologist,rheumatologistorspecialistphysician
Systemicsclerosis Applicationformmustbecompletedbyarheumatologistorspecialistphysician
Wegener’sgranulomatosis Applicationformmustbecompletedbyanephrologist,paediatrician(inthecaseofachild),
pulmonologist,rheumatologistorspecialistphysician
*AlthoughtheseDiagnosticTreatmentPairPrescribedMinimumBenefit(DTPPMB)conditionsarecoveredonallplantypes,thePMBcover
doesnotextendtomedicinemanagement.TheyareincludedontheAdditionalDiseaseListtoallowfundingformedicines.
Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 4 of 9
11.09.2020
5. Application for chronic obstructive pulmonary disease (to be completed by doctor)
If the patient meets the requirement shown below, chronic obstructive pulmonary disease will be approved for funding from the
Chronic Illness Benefit.
PleaseattachtheinitialordiagnosticlungfunctiontestreportwhichshowsanFEV1/FVCpostbronchodilatorreadingof<70%
6. Application for chronic renal disease (to be completed by doctor)
If the patient meets the requirements listed in either A or B below, chronic renal disease will be approved for funding from the
Chronic Illness Benefit.
Pleasetickthe toindicateyes
A. Previously diagnosed patients
Thepatienthasbeendiagnosedwithchronicrenaldiseaseandisundergoingdialysis
B. Please attach a laboratory report that shows a creatinine clearance of <60 ml/min
7. Application for diabetes type 2 (to be completed by doctor)
If the patient meets the requirements listed in either A, B or C below, diabetes type 2 will be approved for funding from the Chronic
Illness Benefit.
Pleasetickthe toindicateyes
A. Type 2 diabetic on Insulin
Thepatientisatype2diabeticoninsulin
B. Please attach the initial or diagnostic laboratory results that confirm the diagnosis of diabetes type 2
Please note that finger prick and point of care tests are not accepted for registration on the Chronic Illness Benefit.
Dotheseresultsshowoneofthefollowing:
Afastingplasmaglucoseconcentration≥7.0mmol/l
Arandomplasmaglucose≥11.1mmol/l
A2-hourpost-loadglucose≥11.1mmol/lduringanoralglucosetolerancetest(OGTT)
AnHbA1C≥6.5%
C. Initial or diagnostic laboratory test results are not available
Thepatientwasdiagnosedwithdiabetestype2morethanfiveyearsagoandtheinitialordiagnosticlaboratoryresultsarenotavailable
Important:pleasenotethatnoexceptionswillbemadeforpatientsbeingtreatedwithMetforminmonotherapy.
8. Application for haemophilia (to be completed by doctor)
If the patient meets either of the requirements listed below, haemophilia will be approved for funding from the Chronic Illness
Benefit.
Pleasetickthe toindicateyes
Please attach the initial or diagnostic laboratory results that confirms the diagnosis of haemophilia
Dotheresultsshowoneofthefollowing:
AfactorVIIIlevelof<5%
AfactorIXlevelof<5%
Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 5 of 9
11.09.2020
9. Application for hyperlipidaemia (to be completed by doctor)
If the patient meets the requirements listed in either A, B or D below, hyperlipidaemia will be approved for funding from the
Chronic Illness Benefit. Information provided in section C will be reviewed on an individual basis.
Pleasetickthe toindicateyes
A. Primary prevention
Pleaseattachtheinitialordiagnosticlaboratoryresultsthatconfirmsthediagnosisofhyperlipidaemia.
PleaseusetheFramingham10-yearriskAssessmentCharttodeterminetheabsolute10-yearriskofacoronaryevent
(2012 South Africa Dyslipidaemia Guideline)andindicateifthepatient:
Hasariskof20%orgreateror
Hasariskof30%orgreaterwhenextrapolatedtoage60
Please indicate if the patient is:
Asmokerorhaseverbeenasmoker
OntreatmentforHypertension
mmHG
Familial hyperlipidaemia
Thepatientwasdiagnosedwithhomozygousorheterozygousfamilialhyperlipidaemiaandthediagnosiswasconfirmedbyan
endocrinologist,lipidologistorlipidclinic.
Pleaseattachsupportingdocumentation.
B. Secondary prevention
Pleaseindicateifthepatienthas/hashadahistoryofoneofthefollowing:
Diabetestype2
Stroke
TIA
Coronaryarterydisease
Anyvasculitideswherethereisassociatedrenaldisease(Pleaseattachthesupportinglaboratoryreportreflectingcreatinineclearance)
Solidorgantransplant(PleasesupplytherelevantclinicalinformationinSectionC)
Chronicrenaldisease(Pleaseattachthesupportinglaboratoryreportreflectingcreatinineclearance)
Peripheralarterialdisease(Pleaseattachthedopplerultrasoundorangiogram)
Diabetestype1withmicroalbuminuriaorproteinuria(Pleaseattachthesupportinglaboratoryreport)
C. Please supply any other relevant clinical information about this patient that supports the diagnosis of hyperlipidaemia
D. Initial or diagnostic laboratory test results are not available
Thepatientwasdiagnosedwithhyperlipidaemiamorethanfiveyearsagoandtheinitialordiagnosticlaboratoryresultsarenotavailable
Pleasesupplythepatient’scurrentbloodpressurereading
Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 6 of 9
11.09.2020
10. Application for hypertension (to be completed by doctor)
If the patient meets the requirements listed in either A, B or C below, hypertension will be approved for funding from the Chronic
Illness Benefit
Pleasetickthe toindicateyes
A. Previously diagnosed patients
Thediagnosiswasmademorethansix(6)monthsagoandhasthepatientbeenontreatmentforatleastthatperiodoftime
B. Please indicate if the patient has/has had a history of one of the following:
Chronicrenaldisease
Stroke
Peripheralarterialdisease
Myocardialinfarction
Coronaryarterydisease
PriorCABG
Hypertensiveretinopathy
Pre-eclampsia
TIA
C. Newly diagnosed patients
Thediagnosiswasmadewithinthelastsix(6)monthsandthepatienthasa:
Bloodpressure≥130/85mmHgandpatienthasdiabetesorcongestivecardiacfailureorcardiomyopathy
Bloodpressure≥160/100mmHg
Bloodpressure≥140/90mmHgontwoormoreoccasions,despitelifestylemodificationforatleast6months
Bloodpressure≥130/85mmHgandthepatienthastargetorgandamageindicatedby
Leftventricularhypertrophyor
Microalbuminuriaor
Elevatedcreatinine
Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 7 of 9
11.09.2020
HasbeentreatedwithRadioactiveiodine
11. Application for hypothyroidism (to be completed by doctor)
If the patient meets the requirements listed in either A, B or C below, hypothyroidism will be approved for funding from the Chronic
Illness Benefit.
Pleasetickthe toindicateyes
A. Please specify the relevant clinical information. The patient:
HashadaThyroidectomy
HasbeendiagnosedwithHashimoto'sThyroiditis
B. Please attach the initial or diagnostic laboratory results that confirm the diagnosis of hypothyroidism, including TSH and T4
levels.
Dotheseresultsshow:
AraisedTSHandreducedT4level
AraisedTSHbutnormalT4levelandhigherthannormalthyroidantibodies
AraisedTSHlevelofgreaterthan10mIU/lontwoormoreoccasionsatleastthreemonthsapartinapatientwithnormalT4levels
C. Initial or diagnostic laboratory test results are not available
Thepatientwasdiagnosedwithhypothyroidismmorethanfiveyearsagoandtheinitialordiagnosticlaboratoryresultsarenotavailable
12. Application for osteoporosis (to be completed by doctor)
If the patient meets the requirements listed in either A, B or C below, osteoporosis will be approved for funding from the Chronic
Illness Benefit.
Pleasetickthe toindicateyes
A. Osteoporotic fracture
Thepatienthasbeendiagnosedwithanosteoporoticfractureofthespine,forearm,hiporshoulder
B. Spinal wedging
Thepatienthas1spinalwedge.PleaseattachthediagnosingDEXAbonemassdensityscanresults.
Thepatienthas2ormorespinalwedges.
C. Please attach the diagnosing DEXA bone mass density scan results that confirm the diagnosis of osteoporosis
Dotheseresultsshow:
T-scoreoftheAPSpineis≤-2.5
T-scoreoftherighthipis≤-2.5
T-scoreofthelefthipis≤-2.5
T-scoreoftherightfemoralhipis≤-2.5
T-scoreoftheleftfemoralhipis≤-2.5
Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 8 of 9
11.09.2020
13. Medicine required (to be completed by doctor)
Toassistusinpayingclaimsforthediagnosisofcondition(s)fromthecorrectbenefits,pleaseensurethatyouincludethedate when the
condition was first diagnosedinthetablebelow.
ICD-10 code Condition description Date when
condition was
first diagnosed
Medicine name, strength and dosage How long has the patient
used this medicine?
Years Months
Notes to doctors
13.1. PleaseensurethattherelevantICD-10diagnosiscode(s)areusedwhenyousubmityourclaimstotheSchemetoensurepaymentfrom
thecorrectbenefit.
13.2. PleaseincludetheICD-10diagnosiscode(s)whenreferringyourpatienttothepathologistsand/orradiologists.Thiswillenablethe
pathologistsandradiologiststoincludethisinformationontheirclaimsandallowustocomplywithlegislationbypayingPrescribed
MinimumBenefits(PMB)claimscorrectly.
13.3. Wewillapprovefundingforgenericmedicine,whereavailable,unlessyouhaveindicatedotherwise.
13.4. Pleasesubmitalltherequestedsupportingdocumentswiththisapplicationtopreventdelaysinthereviewprocess.
13.5. Shouldyoumakechangestoyourpatient'streatmentplan,youneedtoletusknowsothatwecanupdatetheirchronicauthorisation/s.
Youcandothisbye-mailingthenewprescriptiontousorbyloggingontoHealthIDtomakethechanges,providedthatthepatienthas
givenconsent.Ifyouoryourpatientdonotletusknowaboutchangestothetreatmentplan,wemaynotpayclaimsfromthecorrect
benefit.
Signatureofdoctor Date - -
Please only sign if information is true, complete and correct.
D D M M Y Y Y Y
Discovery Health Medical 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
DHMCIB002
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised
financial services provider.
Page 9 of 9
11.09.2020
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Chronic Illness Benefit Application form 2020 (Law for All South Africa)

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Completed 29 November 2020

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