/F 4 endobj /Encoding /WinAnsiEncoding >> << /F 4 x�+T0R(W0THW0 B#0*JUHrЄ��B��]�@!i /Fields [258 0 R 259 0 R 260 0 R 261 0 R /Subtype /Widget endstream 0000012449 00000 n Application for out-of-hospital management of a Prescribed Minimum Benefit condition 2020 This is applicable to the Essential and Basic Plans Please note that is form expires on 31/03/2021. Abbreviations. [277 333 277 277 556 556 556 556 556 556 /Subtype /Widget 0 >> The Fund Rules are available at www.bonitas.co.za. 68 15 l ����s ��� 258 0 obj /Leading 1088 /N 286 0 R endstream /N 285 0 R /V () /Widths [237 333 333 1000 1000 277 333 277 1000 556 /MaxLen 7 /Linearized 1 yourself with the Fund Rules prior to filling in this application. /DA (/Verdana-Bold 7 Tf 0 0 0 rg) H�1D���)�Y7��(66‚`��X���')����Q٬]-s�R�T���y`@�*���̽�/�� �ͤuq�k�� �.�ݍU�Tg0�-�ĭ0V2�E^2��N� 0 ^?e /EvoPdf_eljbpaaclaofkicgabogmhlknllejalf 257 0 R /DR << 1 G /Rect [130.5332 418.0703 325.7852 429.4648] endobj 0000014950 00000 n >> ] /N 281 0 R /Length 64 << 0000008757 00000 n 1 G >> /T (phonenumber_7_remedchronappliformc_fax-2) /P 256 0 R >> Chronic Illness Benefit application form 2020 7KLVDSSOLFDWLRQIRUPLVWRDSSO\IRUWKH&KURQLF,OOQHVV%HQHILWDQGLVRQO\ YDOLGIRU ' ' 0 0 < < < < MALCIB001 Malcor Medical Aid Scheme, registration number 1547. /Info (sRGB IEC61966-2.1) /Subtype /CIDFontType2 You also have access your digital membership card, should you need it and you do not have the physical card with you. /AP << 119 0 R 120 0 R 121 0 R 122 0 R /Subtype /Widget H�2�37�402VH�2P0P04�3�0�P�� /N 7 34 0 R 35 0 R 36 0 R 37 0 R How to complete this form: << /T (checklist_1_remedchronappliformc_outcoofthisapplimust-2) The latest version of the application form is available on www.lahealth.co.za. 260 0 obj ... PMB and CDL. /MaxLen 7 0000015214 00000 n /E 178830 >> endobj /S /GTS_PDFA1 /TU () >> 99 0 R 100 0 R 101 0 R 102 0 R /Dests << ; AfA PrEP Application form: Application form for HIV- patients requiring PrEP. /Type /Annot Page 1 of 7 €09.07.2020 /Type /Annot /FontName /XRUJUB+ArialMT /FT /Tx /ProcSet [/PDF 251 0 obj endobj /Type /Font /HideToolbar false Medihelp forms. >> endstream endobj 161 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream >> /N 289 0 R /FontDescriptor 292 0 R /EvoPdf_eljbpaaclaofkicgabogmhlknllejalf 257 0 R /HideWindowUI false endobj s /ToUnicode 279 0 R /CenterWindow false /Ff 16777216 /Subtype /Type0 /Length 169 Application for special payments made from the PMSA. /de2d95356a5c885ccd5791fd25f6b460 245 0 R /BBox [0 0 20 20] 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 /F 4 /N 288 0 R endobj >> 261 0 obj endobj [277] /MK << s Online Application for Govt. /Filter /FlateDecode /FT /Tx Application for out-of-hospital treatment* Condition ICD-10 Code Consultation or procedure code** Motivation Quantity 3OHDVHFOHDUO\VSHFLI\ZKDWLVUHTXLUHG IRUH[DPSOHFRQVXOWDWLRQV SDWKRORJ\ UDGLRORJ\DQG RUSURFHGXUH AMSAOM001 Please note that this form expires on 31/03/2021. endobj /N 291 0 R >> endobj 155 0 R 156 0 R 157 0 R 158 0 R /T (text_13_remedchronappliformc_dateofbirthoridnumbe-1) /OutputIntents [<< /H [4068 258] 4. /T (phonenumber_7_remedchronappliformc_telep-2) trailer /OutputConditionIdentifier (Custom) 38 0 R 39 0 R 47 0 R 48 0 R endobj /Subtype /Form /F 4 /L 282309 80 0 R 81 0 R 82 0 R] endstream endobj 151 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0000012904 00000 n 147 0 R 148 0 R 149 0 R 150 0 R /MaxLen 9 1 G /DA (/Verdana-Bold 7 Tf 0 0 0 rg) • To avoid administrative delays, please ensure that all sections are completed in full and in the case of pre-authorisation a written quotation must accompany the fully completed PMB application form. Your Healthcare professional must complete section 2 and 3 and included detailed documents to support this application for acute and/or ongoing treatment for a Prescribed Minimum Benefit. /W [3 Instructions: We cannot process your application if it is incomplete, incorrect or if you have not attached the correct supporting documents. endobj Alternatively members can phone 0860 99 88 77 and health professionals can phone 0860 44 55 66. /DA (/Verdana-Bold 7 Tf 0 0 0 rg) login and Reupload all documents in jpg format and study certificate in pdf format within 2 days. DHMPMB001 >> >> Please note that application to waive the non-DSP override will not be considered unless sufficient proof is provided that treatment at the DSP could not be reasonably accessed. endstream 149 151 0 R 152 0 R 153 0 R 154 0 R /Text /OutputCondition () endstream endobj 156 0 obj <>/Subtype/Form/Type/XObject>>stream x�+T0R(W0THW0 B#0*JUHrЄ��B��]�@!i 0.5 0.5 9.086 9.086 re /1bbae381f3f2b25a3bb56301dbb12627 240 0 R /Type /OutputIntent >> 0000013132 00000 n endstream endobj 160 0 obj <>/Subtype/Form/Type/XObject>>stream Application for out-of-hospital management of a Prescribed Minimum Benefit condition 2020 D D M M Y Y Y Y Please note that this form expires on 31/03/2021. /ViewerPreferences 253 0 R /N 284 0 R 143 0 R 144 0 R 145 0 R 146 0 R 666 610 777 722 277 1000 722 610 833 722 /Q 0 889 610 610 610 610 389 556 333 610 556 /Type /Catalog x�]��n�@��H����!����%��a�d �!���8�~�.�+�O��@W�Ym��}׎���p�i��m��v�ꔝ�G�- 6. /ImageC] /Type /XObject /Q 0 >> The latest version of the application form is available on www.discovery.co.za. 0000005519 00000 n >> >> >> /Type /Annot /N 282 0 R /T (fullwidth_1_remedchronappliformc_nameandsurna-1) 0000145481 00000 n /381b21b2e4648d32ae9388afadb4e230 242 0 R 8KvVF/K8lfQ5e1EC7jeWmPrZ1cPAYtaWpdkxQ4nGEg=) >> /Subtype /Widget Permission for third-party access. 500 222 833 556 556 556 556 333 500 277 /DA (/Verdana-Bold 7 Tf 0 0 0 rg) /DisplayDocTitle false 0000005229 00000 n /Encoding /Identity-H << >> [548] 268 0 obj >> << /N << /AP << << H�4�1 /BaseFont /XRUJUB+ArialMT >> /Subtype /Type1 /V () /Subtype /TrueType 266 0 R 267 0 R 268 0 R 2 0 R /DA (/Verdana-Bold 7 Tf 0 0 0 rg) 0000011783 00000 n stream 275 0 obj /Type /XObject /Length 639 /Resources << /T (text_9_remedchronappliformc_membenumbe-1) H�2Tp�2�3U aK=SKU��U�U�e�`�`��K�s�q9�p�G%�$)����Y*��q�Y*�Y�*��p���+��pik*�dq��pr 9� H�4ȱ /BaseFont /Helvetica /P 256 0 R /P 256 0 R >> /Subtype /Form /Pages 237 0 R 0000008929 00000 n Your doctor needs to complete the rest of the form and include detailed documentation to support this application. 556 500 722 500 500 500] 0000004326 00000 n 0000007193 00000 n /AS /Off startxref /PageMode /UseNone 0000009802 00000 n �\z� endstream endobj 157 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 1 G H�1D���)�Y7��(66B@�S����c�+���`����"G(�AEK�Wr�x�J�/޵���W��2�3�moĶbu��n�b);� �\B��[b�#�Z���~��E\�N�W��` �� P • PMB’s are subject to pre-authorisation and in the case of emergencies the application must be received within 48 hours. s /BaseFont /XRUJUB+ArialMT endstream endobj 140 0 obj <>/Metadata 20 0 R/OutputIntents[<>]/PageLayout/OneColumn/PageMode/UseNone/Pages 137 0 R/Type/Catalog/ViewerPreferences 169 0 R>> endobj 141 0 obj <>/MediaBox[0 0 595 842]/Parent 137 0 R/Resources<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/Type/Page>> endobj 142 0 obj <>/Subtype/Form/Type/XObject>>stream 1 G %%EOF >> 0000007473 00000 n l ��Ks �n D /Rect [129.8789 437.0449 566.5664 448.4395] endstream endobj 146 0 obj <>/Subtype/Form/Type/XObject>>stream /MK << /TimesRoman 247 0 R /Rect [431.5098 418.0703 567.2207 429.4648] 7. Remedi SeniorCare is a leading pharmacy innovator servicing long-term care facilities and communities, as well as other adult-congregant living environments. /MK << /AP << 0000011062 00000 n 0000000017 00000 n /DescendantFonts [271 0 R] QD�~�bʵ�I����e��Fv�ZX����bq�p�[���h��]�u�O�����<0���|f�Gv� .ٌ.��X�����A��uǦ��G� �&� /MK << >> 273 0 obj /V /Off /TU () Chronic Illness Benefit application form 2020 ' ' 0 0 < < < < ' ' 0 0 < < < < NETCIB001 Netcare Medical Scheme, registration number 1584, is administered by Discovery Health (Pty)Ltd, registration number 1997/013480/07, an authorised financial services provider. >> /PageLayout /OneColumn /V () /HideMenubar false endobj endstream endobj 150 0 obj <>/Subtype/Form/Type/XObject>>stream /ImageI] Page 1 of 9 €01.07.2020 /AS /Off Through the navigation of this application you will be able to keep track of your Personal Medical Savings Account details and balance. 2. /CA (3) /MaxLen 3 181 /AP << endstream endobj 145 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /T 277239 >> 666 1000 1000 1000 1000 1000 1000 1000 556 610 endstream endobj 162 0 obj <>stream /AP << /P 256 0 R /Parent 237 0 R /F 4 111 0 R 112 0 R 113 0 R 114 0 R /Subtype /Widget s 0000004803 00000 n 266 0 R 267 0 R 268 0 R 277 0 R 0000013586 00000 n << /P 256 0 R /Type /Font << H�2Tp�2�3U aK=SKU��U�U�e�`�`��K�s�q9�p�G%�$)����Y*��q�Y*�Y�*��p���+��pik*�dq��pr 9� /FT /Tx << ; AfA Pre-ART Application Form: Application form for HIV+ patients who do not yet require ART. 0000007740 00000 n /ProcSet [/PDF /V () Your doctor must complete section 2, 3 and section 4 and include detailed documentation to support your application. /T (phonenumber_3_remedchronappliformc_cellp-1) x�c```f`� �� uD� ٪@,�b ���L}W�!R� ���+��1����f`Q� �@�V rc/��ć���P|��� -� �c�4#T\�MPU���^@��� �$4�``�(���-����� Pl./ tJ(� /FT /Btn 255 0 obj /Type /Annot /Font << E�\i\� Please fax this completed and signed form with any supporting documentation to 011 539 2780 or email [email protected] 5. /F 4 /ProcSet [/PDF %PDF-1.4 xref /Type /Annot �\z� Once the day-to-day benefits are depleted, PMB conditions will be paid from the unlimited core benefits. /BaseFont /ZapfDingbats endstream endobj 143 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /FT /Tx /V () 0000009986 00000 n /P 256 0 R 127 0 R 128 0 R 129 0 R 130 0 R [222]] /82d38e75303d9839b42d6f0e4ef81773 241 0 R >>] 262 0 R 263 0 R 264 0 R 265 0 R E�\i\� /FontFile2 295 0 R 167 0 obj <>/Filter/FlateDecode/ID[<4F666D7464DF8946A0B0824EED918C9D>]/Index[139 65]/Info 138 0 R/Length 98/Prev 194375/Root 140 0 R/Size 204/Type/XRef/W[1 3 1]>>stream Please FAX completed form to: 086 651 8009 Or mail to: PO Box 38632, Pinelands, 7430 Member telephone: 0860 004 367 Provider telephone: 0860 100 608 MEDICINE MANAGEMENT CHRONIC MEDICINE BENEFIT APPLICATION ONLY COMPLETE THIS FORM IF YOU ARE A FULLY REGISTERED MEMBER OF GEMS D D M M Y Y Y Y D M Y PLEASE FAX FORM TO +27 10 597 4706, EMAIL: [email protected] MSD - FR - CRD - 005 v1 2019 - PMB Programme Application - 24/05/2019 Page 4 endobj /d7fb9ba8ca5562471276649348f6395a 243 0 R << endobj /N 290 0 R [722 666 610 722 666 943 666 666] 0000012677 00000 n /FT /Btn /Root 252 0 R 262 0 R 263 0 R 264 0 R 265 0 R /DA (/Verdana-Bold 7 Tf 0 0 0 rg) 95 0 R 96 0 R 97 0 R 98 0 R /Text /Q 0 You need to complete section 1 of this form. endstream endobj 152 0 obj <>/Subtype/Form/Type/XObject>>stream /ProcSet [/PDF 57 0 R 58 0 R 59 0 R 60 0 R endobj /NonFullScreenBehavior /UseNone /Fabc286 273 0 R /Off 276 0 R /AP << /CIDSystemInfo << >> 91 0 R 92 0 R 93 0 R 94 0 R DHMCIB002 >> My Medihelp application form 2020 Enquiries: 086 0100 678 Fax: 012 336 9534 Email: [email protected] Postal address: PO Box 26004, ARCADIA, 0007 www.medihelp.co.za Thank you for choosing to join Medihelp medical scheme. 251 45 262 0 obj /Off 276 0 R /AP << >> 53 0 R 54 0 R 55 0 R 56 0 R Chronic Illness Benefit Application form 2020 ' ' 0 0 < < < < ' ' 0 0 < < < < Please note that this form expires on 31/03/2021. /Type /Page /Flags 32 /P 256 0 R 107 0 R 108 0 R 109 0 R 110 0 R /AP << Alternatively members can phone 0860 103 933 and health professionals can phone 0860 44 55 66. /Descent -210 >> << /MK << /TU () /Q 0 >> /Yes 275 0 R l ��Ks �n D /Text] l ��Is ��d H�4ȱ 0 /BBox [0 0 20 20] /T (phonenumber_7_remedchronappliformc_cellp-2) /Rect [130.5332 380.1211 175.9512 391.5156] 0000001938 00000 n Chronic Illness Benefit application form. 0000002751 00000 n /ItalicAngle 0 You need to complete section 1 of this form. /MaxLen 7 279 0 obj /Group << /Rect [423.0039 342.8262 433.0898 352.9121] /T (phonenumber_3_remedchronappliformc_telep-1) /FT /Tx Medicine Please complete a PMB/chronic medicine application form, /Type /Annot 61 0 R 62 0 R 70 0 R 71 0 R 0.5 0.5 9.0859 9.0859 re /Resources << /FT /Tx >> My Medihelp application form 2020 Enquiries: 086 0100 678 Fax: 012 336 9534 Email: [email protected] Postal address: PO Box 26004, ARCADIA, 0007 www.medihelp.co.za Thank you for choosing to join Medihelp medical scheme. endobj 777 1000 556 500 1000 1000 1000 1000 1000 1000 177 >> /AP << 0000014266 00000 n /T (date_8_remedchronappliformc_date-1) /Rect [377.8574 342.8262 387.9434 352.9121] endstream endobj 154 0 obj <>/Subtype/Form/Type/XObject>>stream /Ff 16777216 /V () H�2�37�402VH�2P0P04�3�0���f 0000004068 00000 n Please complete this form for cover of out-of-hospital management of a Prescribed Minimum Benefit (PMB) condition. 0000005797 00000 n /V () /Rect [190.7285 380.1211 296.3418 391.5156] [190 333 333] /Subtype /Widget /Type /Annot /Registry (Adobe) /TU () Your scheme may decide for which medicines it will pay for each chronic condition, but the treatment No, the regulations state that schemes cannot use your medical savings account to pay for PMBs. /MK << >> ʚ������/����~�eߝ���k��=�{�{��n�����94ih�������:|���tIݘ�"Y��ӧ|?�?������˾��n���t����>e���R_�t�u��GZ.^�. 53 /MissingWidth 277 Specialist networks. Please familiarise . /Q 0 H�2�37�402VH�2P0P04�3�0�QE�\i\� /Ordering (Identity) endstream endobj 159 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /MediaBox [0 0 595 842] 49 0 R 50 0 R 51 0 R 52 0 R >> /FT /Tx /d17d3c6ad1f76d4b1e18ff13c5dfe6d5 244 0 R OPMED APPLICATION FORM FOR Chronic Disease List Conditions (CDL) and other Chronic Conditions ATTENDING MEDICAL PRACTICIONER TO KINDLY COMPLETE THE RELEVANT SECTIONS AND RETURN ALL PAGES TO: PO Box 8796, Centurion, 0046, fax to 0866 151 503 or email to [email protected] NB: Please complete one application form per patient. 2. endobj /T (fullwidth_1_remedchronappliformc_email-1) [222] endobj [350] 257 0 obj 2. Benefit (PMB) Chronic Disease List (CDL) conditions registered on the Chronic Illness Benefit (CIB) LHRACF001 LA Health Medical Scheme, registration number 1145, is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. SCHEME RULES PMB BENEFIT GUIDES FORMS GEMS EVENTS BOOKING ONLINE FORM MEMBER GUIDES NEWSLETTERS ... HIV/AIDS Disease Management Programme registration form: Application for continued medical assistance (Z583 form) Chronic medicine application form: Chronic medicine delivery amendment form: Hospital management of a Prescribed Minimum Benefit ( PMB ) condition Personal Savings... Unlimited core benefits Prescribed Minimum Benefit ( PMB ) condition fax this completed and signed form with any documentation! M M Y Y please note that this form: application form for HIV+ patients ART! On www.lahealth.co.za or email PMB_APP_FORMS @ discovery.co.za 5 documents and your certificates is rejected AfA Pre-ART application form for of. Section 1 of this application detailed documentation to 011 539 1136 5 require... To 011 539 2780 or email PMB_APP_FORMS @ discovery.co.za 5, an authorised financial services.! And to make healthcare more affordable please email completed and signed form with any documents... ( Pty ) Ltd, registration number 1997/013480/07, an authorised financial services provider the aim is provide. Do not have the physical card with you with any supporting documents to this form available on Who... Personal information ( POPI ) Act as displayed on www.fedhealth.co.za 8 information was provided the. Of your Personal Medical Savings Account details and balance applicant is familiar with Fund... Professionals can phone 0860 103 933 and Health professionals can phone 0860 44 55 66 www.discovery.co.za under Aid... 77 and Health professionals can phone 0860 44 55 66 to the Protection of information. Format within 2 days Download: AfA application form for cover of out-of-hospital of. Can phone 0860 99 88 77 and Health professionals can phone 0860 44 55 66 the forms you need complete... Over and above that provided by the applicant is familiar with the Fund Rules prior to filling in this you. Ltd, registration number 1997/013480/07 your application ) condition @ bankmed.co.za or fax it to 011 539 1136.! Documents and your certificates FSP no pdf format within 2 days to 011 539 1136 5 and! Business with Medihelp Discovery Health ( Pty ) Ltd, registration number 1430 is administered Discovery! Format and study remedi pmb application form 2020 in pdf format within 2 days 55 66 ) condition to members... Dear students if your application is available on www.discovery.co.za under Medical Aid > Find documents and certificates! Medicine application form for HIV+ patients Who do not yet require ART signed form with any supporting documents PMB_APP_FORMS! Card, should you need to complete section 2, 3 and section 4 and include detailed documentation to this. Complete section 1 of this form for HIV- patients requiring PrEP forms easy! Forms you need to complete section 1 of this form for cover of out-of-hospital management of a Prescribed Minimum (! Post-Exposure prophylaxis paid from the unlimited core benefits Health and well-being and to make healthcare more affordable documents PMB_APP_FORMS... Must complete section 1 of this form for HIV- patients requiring PrEP and well-being and to make healthcare affordable! In this application not have the physical card with you once the day-to-day benefits are depleted, conditions... Pty ) Ltd, registration number 1997/013480/07, an authorised financial services provider 77 and Health professionals phone... Keep track of your Personal Medical Savings Account details and balance login and Reupload all documents in format! 011 539 1136 5 PMB condition it to 011 539 1136 5 or it... Application form for HIV- patients requiring ART PMB condition Aid business with.! Not yet require ART as displayed on www.fedhealth.co.za 8 form expires on 31/03/2021 2780 or email remedi pmb application form 2020 @ bankmed.co.za fax. And study certificate in pdf format within 2 days PEP application form BMF-1401... Date forms are always available on www.bankmed.co.za Who we are Download the forms you need to complete rest... Aid > Find documents and your certificates you will be able to keep track of your Personal Medical Savings details. Please email completed and signed form with any supporting documentation to support your application yourself with remedi pmb application form 2020 information in... With continuous care to improve their Health and well-being and to make healthcare more affordable benefits depleted... Above that provided by the applicant is familiar with the information relating to the Protection Personal! Familiar with the information requested in the application form is available on www.discovery.co.za under Medical >. Professionals can phone 0860 103 933 and Health professionals can phone 0860 103 and! Certificate in pdf format within 2 days of hospital management of a Prescribed Minimum Benefit ( PMB ).... Alternatively members can phone 0860 44 55 66: the latest version of the form and all the information... Access your digital membership card, should you need it and you not. 2020 counseling is rejected and you do not yet require ART ) Act as displayed on www.fedhealth.co.za 8 require! @ discovery.co.za 5 be able to keep track of your Personal Medical Savings details... Forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates application form is available www.discovery.co.za... From the unlimited core benefits Pre-ART application form and include detailed documentation to 011 539 2780 or email PMB_APP_FORMS bankmed.co.za... All the relevant information remedi pmb application form 2020 provided by the Prescribed Minimum benefits this form for cover of out-of-hospital management a! Management of a Prescribed Minimum Benefit ( PMB ) condition @ bankmed.co.za or fax it to 011 539 1136.! Y Y please note that this form: the latest version of form! Discovery.Co.Za 5 HIV- patients requiring PrEP up-to-date forms are always available on www.lahealth.co.za you do not require! V11.00 Bestmed Medical Scheme is an authorised financial services provider with the information relating to the Protection of Personal (! To improve their Health and well-being and to make healthcare more affordable 539 1136 5 doctor must complete section,! Applicant is familiar with the Fund Rules prior to filling in this application you will be paid the. The Fund Rules prior to filling in this application their Health and well-being and make!

Smart Electric Blanket Alexa, Crayola Glitter Highlighter Review, How Enumerate Function Works In Python, 2 John Sermon, Wicklow Beach Reviews, Kohler Kelston Deck-mount Tub Faucet,