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
