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 should be completed when a member needs additional out-of-hospital treatment that falls outside of the basic level of care provided for
in the Prescribed Minimum Benefits.
Please only complete this form if we have already reviewed a request for funding for your condition as a Prescribed Minimum Benefit. Otherwise
please complete the "Application for out-of-hospital management of a Prescribed Minimum Benefit condition" form.
What you must do
Fill in the form in black ink and print clearly, or complete the form digitally.
All relevant sections must be physically signed by the main applicant and/or doctor and cannot be signed digitally. The main applicant and/or
doctor must sign and date any changes.
You need to complete section 1 and 2 of this form.
Your healthcare professional needs to complete the rest of the form and include detailed documents to support this application.
Please email this completed and signed form with any supporting documents to PMB_APP_FORMS@discovery.co.za or
fax it to 011 539 2780.
You will receive a letter informing you of our decision and the process you should follow.
You may call us if you would like to lodge a formal dispute to a declined decision.
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
Telephone (H) -
Telephone (W) -
Cellphone -
Fax -
Email
Relationship to main member
The outcome of this application can be communicated to me by Email Fax
2. Notes to member
I give permission for my healthcare professional to give Discovery Health Medical Scheme and Discovery Health (Pty) Ltd (as administrator) my
diagnosis and other relevant clinical information required to review my application for Prescribed Minimum Benefits.
I understand that:
2.1. Funding from the Prescribed Minimum Benefit is subject to clinical entry criteria as determined by Discovery Health Medical Scheme.
2.2. Each case will be assessed on its own merit.
2.3. By registering for Prescribed Minimum Benefits, I agree that my condition may be subject to disease management interventions and
periodic review and this may include access to my medical records.
Prescribed minimum benefits appeals form 2020
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.
DHMPMB001
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 3
21.02.2020
2.4. No application for Prescribed Minimum Benefits will be considered for approval unless this application form is complete in full at the time of
its submission.
2.5. 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 and Discovery Health (Pty) Ltd asks for this.
2.6. Consent for processing my personal information:
2.6.1. I give the Scheme and Administrator consent to have access to and process all information (including general, personal, medical or
clinical information) that is relevant to this application.
2.6.2. I understand that this information will be used for the purposes of applying for and assessing my funding request for Prescribed
Minimum Benefits.
2.6.3. I consent to the Scheme and Administrator disclosing, from time to time, information supplied to them (including general, personal,
medical or clinical information) to my healthcare provider, to administer the Prescribed Minimum Benefits.
Signature of patient (if patient is a
minor, main member to sign)
Date - -
I acknowledge that I have read and understood the conditions under “Notes to member” (section 2).
Please only sign if information is true, complete and correct.
3. Application (healthcare professional to complete)
Date of diagnosis
Treatment start date
Treatment end date
3.1. Application for out-of-hospital management
Condition ICD-10 code Consultation or
procedure code**
Motivation Quantity
*Please clearly specify what is required, for example consultations, pathology, radiology and/or procedure.
**The professional billing codes must be supplied for us to review the application.
Please attach any relevant supporting documents, for example pathology tests. If the application is for psychotherapy treatment for members
younger than 13 years of age, the scheme will require the latest DSM V form including the GAF (Global assessment of Functioning) score.
3.2. Application for medicine
Current medicine required (please provide supportive clinical results or information, where necessary)
Condition ICD-10 code Medicine name, strength and
dosage
Number of months
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 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates.
DHMPMB001
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 3
21.02.2020
3.3. Application for radiology
Condition ICD-10 code Description of investigation Quantity per year
3.4. Application for pathology
Condition ICD-10 code Description of investigation Quantity per year
4. Healthcare professional’s details (healthcare professional to complete)
Name and surname
Practice number
Speciality
Telephone -
Fax -
Email
The outcome of this application can be communicated to me by Email Fax
Signature of healthcare
professional
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.com | Customer Care Centre: 0861 123 267 | Website: www.medicalschemes.com
DHMPMB001
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 3
21.02.2020
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