Benefit Option Selection Form

    Section 1: To Be Completed By Employer

    Member No.

    SwaziMed High Benefit Plan
    Swazi-Save Level 1(E1200 savings per annum)
    Swazi-Save Level6 (E7200 savings per annum)
    Standard Benefit Plan
    Swazi-Save Level2 (E3600 savings per annum)
    Swazi-Save Level 7(E8400 savings per annum)
    Medium Benefit Plan
    Swazi-Save Level 3(E3600) savings per annum
    Swazi-Save 8 (E9600 savings per annum)
    Hospital Plan (Hospital Benefit Only)
    Swazi-Save Level 4(E4800 savings per annum)
    Swazi-Save Level 9 (E10800 savings per annum)
    New Generation
    Swazi-Save Level5 (E6000 savings per annum)
    Swazi-Save Level10 (E12000 savings per annum)
    Low Cost Option

    Consent To Disclose Medical Information

    In the event that I or any of my dependants require hospitalization, I hereby consent that any medical practitioner or specialists may disclose all medical information relating to me and any dependants as may be in respect of benefits associated with hospitalization.

    I indemnify the medical practitioners or specialists who have disclosed information in terms of this consent, against any claims that may rise as a result of their disclosure of information.

    Please note that this form must be completed by the employee AND employer (except for direct paying members). Please hand this form to your Human Resources Department or Medscheme branch by no later than 29 December. Should you fail to make to make any selection of the options your membership will remain unchanged.

    Section 2 : To Be Completed By Employer

    (month) (year) for January(year)