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KLERKSDORP

English Edition

AANLYN BEHOEFTE ANALISE
ONS VOORSIEN ONAFHANKLIKE ADVIES AAN DIE WERKGEWER

Section 1 - Member Details

How are you joining? *

Private MemberMember on a Company Billing

If joining on a Company Billing, please provide the company name

Title *

Full Name *

Identity Number *

Email *

Contact Number *

Residential address *

Geographic Region *

Gross income of all income earners *

This is an FSB requirement - we have to show that the premium is affordable. This is kept strictly confidential.

Maximum Monthly Medical Aid spend *

What is the maximum total amount you wish to spend

Number of adults to cover? *

Aged 21 and over (including the main member)

List the ages of all adults, over age 21, separated by commas *

e.g. 48, 46, 22

Number of children to cover? *

Under age 21

List the ages of all children, Under age 21, separated by commas *

e.g. 6, 9, 18

How many children are students? *

Under age 21

List the ages of all the student children, Under age 21, separated by commas *

e.g. 18, 19, 20

Are all applicants currently on an SA registered medical aid? *

YesNo

Have all applicants been on cover for longer than 24 months? *

YesNo

Have any applicants had a break of more than 90 days between scheme membership? *

YesNo

Provide detail of previous membership to a registered medical scheme from age 35 years (if applicable)

Section 2 - Type of Medical Aid Plan Required

Please select the plan type required *

Network Plan (Network Providers – Premium Income based)Hospital Plan with Medical Savings Account (MSA)Hospital Plan without Medical Savings Account (MSA)Comprehensive PlanGap Cover / Top Up

Section 3 - In Hospital (Core Benefit) Requirements

Specialist reimbursement rate required *

Medical aid rates are at 100%, private specialist rates are generally between 300% and 500%. We recommend top up insurance to cover the shortfalls.

Have any applicants previously been diagnosed with cancer? *

YesNo

Do any applicants have any planned hospitalisation?

If 'Yes', please include full details below. If 'No', please ignore.

Are you prepared to utilise a private hospital network? *

Some schemes offer reduced rates if you use their private networks for elective procedures. Emergencies are covered at ANY private hospital.

YesNo

Section 4 - Chronic Conditions

All schemes cover the 26 PMB chronic conditions e.g. hypertension, cholesterol, diabetes. Some schemes cover other conditions too e.g. gout. This section is important as your chronic condition may not be covered by certain options.

Do any applicants have any chronic conditions? *

YesNo

If you answered 'Yes' above, please provide full details

Please include: Member name, chronic condition diagnosed, prescribed medication in use. Use a new line for each condition.

If you have a chronic condition, where will you obtain medication from? *

Some schemes allow you to manage costs by choosing a designated service provider to obtain your chronic medication.

Section 5 - Out of Hospital (Day to Day Benefit) Requirements

Please ESTIMATE the utilisation that all applicants would experience in a typical 12 month period. Day to Day benefits may be provided through medical savings, via a separate savings facility or as stated scheme benefits.

General Practioner (GP) *

Total Spend in 12 months (assume R300 per consultation)

Specialists (e.g. gynaecologist, cardiologist, paediatrician etc.) *

Total Spend in 12 months (assume R600 per consultation)

Acute (Prescribed) Medication

Total Spend in 12 months - for medication prescibed by a GP or Specialist *

Optometry (glasses, contact lenses) *

Total Spend in 12 months

Dentistry *

Total Spend in 12 months

Other (Physiotherapy, Chiropractor, OT etc.) *

Total Spend in 12 months for all other medical providers

Other Specific Cover *

Total spend on specific items e.g. hearing aids, wheelchairs etc. Please list your requirements in detail below.

Section 6 - Ancilliary Benefits

Please indicate if you would like assistance in any of the following areas. We have a network of specialist, professional partners to assist our clients with all financial needs.

I would like assistance with

You can select more than one area

If you would like us to advise you on one or more of these benefits, please provide us with full details of your specific need or request

Section 7 - Source

How did you hear about CMAC Klerksdorp

This is important for our records.

If applicable, Who referred you to us?

Can you provide details of a relative, friend or family member who may need assistance or help in terms of any one/more of the products we provide?

Section 8 - Client Declaration

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AANSOEK PROSES
VOLGENS DIE REGULASIES VAN

Mediese Skemas wet 131 van 1998 en die finansiële advies- en tussengangerdienste van 2002. Ons het sekere vereistes wat voor die verskaffing van kliënte met raad voldoen moet word.

1. As onafhanklike adviseurs moet ons sekere onhullings maak vir kliënte. Dit is beskikbaar vir aflaai en ondertekening en kan per epos of faks na ons terug gestuur word. Geen advies kan gegee word sonder hierdie dokumentasie op leër nie.

2. Ons moet vasstel wat jou spesifieke behoeftes is met betrekking tot gesondheidsorg. Dit word gedoen deur middel van die Mediese Behoeftes Analise(MBA) en die fokus op bekostigbaarheid, die vlakke van dekking benodig beide in en uit die hospitaal, chroniese siektes en enige spesifieke behoeftes wat jy mag hê.

3. By die ontvangs van die MBA, kan ons daarvolgens aanbevelings maak volgens die inligting wat die kliënt aan ons verskaf het.

4. Indien ons raad aanvaarbaar is, stuur ons vir die kliënt adviesrekord vorms tesame met die aansiekvorms.

5. Alle vorms moet volledig voltooi en onderteken wees wanneer dit ons kantoor bereik sodat ons dit vir die skemas kan inhandig.

6. Sodra die skema ‘n besluit rakende u aansoek gemaak het, sal ons kantoor u dadelik kontak om die aanvaarding te teken.