General Details Name: Surname: Email: Cell Number:
The contents of this form will be kept in strict confidence and provide the basis upon which the scheme will consider membership. SECTION 1: GENERAL I hereby apply to be admitted as a member of the Scheme and agree to abide by and be bound by it's rules and regulations.
I certify that all the information given is true and correct and agree that any false statements in this application shall render my membership null and void.
I hereby authorise my employer to deduct from my salary/wage any such amount as I may lawfully owe to the SwaziMed and to remit such amounts to SwaziMed. Furthermore, I understand I shall be held liable for any legal costs incurred in the recovery of any amounts owing to SwaziMed.
I hereby authorise any doctor or other person, who may be in possession of or hereafter acquire information concerning my health or the health of any of my dependants, to disclose this information to the Scheme.
I understand that once I am enrolled as a member I may not terminate my membership voluntarily and that membership may only be terminated once I leave my current employment or (in the case of a female member) I become entitled to dependant membership of another Scheme.
SECTION 2: MEMBERSHIP OF OTHER MEDICAL AID SCHEMES Please give details of membership of any other medical aid scheme(s) prior to this application.
NOTE: Please attach any old membership cards but submit a certificate of membership of previous scheme(s), covering at least the two years immediately prior to the date of this application.
SECTION 3:PERSONAL DETAILS: PLEASE COMPLETE AND SIGN THIS SECTION
Email Address
Designation e.g Manager/Accountant etc
Address:
Cellular Number:
Telephone Number:
Name:
Banking Details Bank Name
Account Type (Current/Savings)
O = Child over 21 years (own, adopted or stepchildren) H = Husband
S = Sex M = Males F = Females
D = Description T = Type
Dependant Details
Date of Benefit:
Date of Birth:
Payroll Number:
Income Category:
No. of Deps:
Member's Share of Contribution:
Employer's Share of Contribution:
Total Monthly or Weekly Contribution:
We confirm that the applicant is employed by us and commenced employment on (date) and that contributions are being deducted in accordance with the applicant's income and the number of eligible dependants and in terms of the appropriate contribution table.
Company Name:
Position (Designation):
1.Any disorder of the heart? e.g. Rheumatic fever, heart murmer, coronary artery2.High blood pressure or disease of the vessels or circulatory disorder? e.g. cramp during exercise, stroke, high cholestorol, hardening of arteries etc3. Any respiratory or lung diseases? e.g. asthma, bronchitis, persistent cough, tuberculosis4.Any disorder of the digestive system, gall bladder, pancrease, or liver? e.g. actual or suspected gastric or duodenal ulcer, recurrent indigestion, hiatus hernia, anal bleeding, haemorrholds or jaundice.5.Disease or disorder of kidneys, bladder, or reproductive organs? e.g. Albumin in urine, kidney stones, prostalitis, venereal disease, infertility or impotence.6.Any nervous or metal complaint? e.g. epilepsy, blackouts, anxiety state or depression.7.Any type of nerve ailment? e.g loss of sensation, numbness, or paralysis etc.8.Ear, eye, nose or throat disorder? E.g. ear discharge, defective vision.9.Disorder or disease of skin, muscles, bones, joints, limbs, spine? e.g. psoriasis, arthritis, gout, slipped disc or other back trouble, etc.10.Diabetes, hormonal imbalance, glandular or metabolic disease, thyroid or blood disorder?11. Cancer, growth of tumor of any kind?12.Any other illness, disorder, operation, disability or accident? e.g. fractured nose, breathing disorders, mammary hypertrophy (enlarged breasts with associated side effects) etc13.Are you or your dependants currently undergoing or expecting to undergo any medical, dental, or surgical treatment?14.Are you (if female) or any of your dependants pregnant? if yes, state the expected date of confinement below15.Have any exclusions been imposed by any medical scheme on which you or your dependants have been registered? If yes, please state details below.
Date details for question 14: Details for question 15:
SCHEDULE Question Number: Name of Patient: Nature and duration of compliant and full details of treatment being or expected to be received. Name and telephone number of attending Doctor of Hospital
When did you or your dependants last have symptoms or received treatment?
Please attach files (PDF files only):
Failure to disclose all relevant and / or correct information may adversely affect the benefits available to you and your family.
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