New Application and Medical Disclosure Form

Thank you for applying to become a member of SEDMED. This Medical Disclosure Form is to be completed by all new entrants to SEDMED.

Important:
In order to protect the interests of existing members of SEDMED, the trustees have introduced a procedure whereby they reserve the right to restrict or exclude benefits for those new entrants with a known prior existing condition, for a maximum period of 12 months. This questionnaire must be completed in order to assess your and your dependant’s(s’) eligibility for benefits under SEDMED.

New Application and Medical Disclosure Form

A. About yourself (principal applicant):

Name
Name
Full name(s)
Surname
Physical Address
Physical Address
City
Province
Postal Code
Country
Postal Address
Postal Address
City
Postal Code

Maximum file size: 8MB

For SEDMED to communicate with you
Is your spouse employed at any of the business units within the Group?
Is he/she already a registered member of SEDMED?

Principal Applicant’s Banking Details:

Account holder
Account holder
Full name(s)
Surname
eg: cheque, savings, transmission

Maximum file size: 8MB

B. About your spouse

Are applying for membership for your spouse?

Spouse Details

Name
Name
Ful Name(s)
Surname
Maiden name

Maximum file size: 8MB

For SEDMED to communicate with you
Confirmation of marriage:
If you are legally married then please attach a copy of your marriage certificate.

Maximum file size: 8MB

C. About your child dependant(s)

Are applying for membership for your child dependants?

Child Dependant(s) Details

Please note: A child may be registered as a dependant, provided:
  1. The child is the natural child, legally adopted child, stepchild, legally fostered child (for the placement period only) of the principal applicant and/or spouse.
  2. The child is under the age of 21 years AND not earning a regular income.
  3. The child is a full-time student under the age of 26 years (valid proof of registration as a full-time student at a recognised institution is required).
  4. The child is physically and/or mentally disabled (proof of such disability is required).
Name
Name
Ful Name(s)
Surname

Maximum file size: 8MB

Birth certificates of newly born children
Proof of studies for all dependants over 18 years of age
Copy of ID or Passport
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D. Health questionnaire and declaration

This section is extremely important. Any misstatement in, or omission from this form may lead to refusal to admit any claims for treatment given, suspension or termination of membership. A 12-month condition-specific waiting period may be applied to any condition declared, subject to the requirements of the Medical Schemes Act No. 131 of 1998. It is essential to declare all conditions/illnesses/symptoms, no matter how insignificant they may seem. If the space provided below is insufficient, please attach additional information to this application form. Disclosure is not limited to the example conditions cited below. Related, consequent and suspected conditions and symptoms must also be disclosed. Should a new medical condition arise or be diagnosed between the time of completing this form and the commencement date of membership, please inform the Scheme immediately. Medical reports may be required in respect of the conditions declared.
1. Medical history
Have you or any of your dependants for whom you are applying for membership sought any advice, been diagnosed with or been treated or have/had symptoms for any conditions in the last 12 months? If YES, please state full details of each instance in the schedule following question 1.12.

Section

1.1 Heart and circulation conditions
e.g. chest pain, palpitations, shortness of breath, coronary heart disease, angina, heart attack. arrhythmia high blood pressure YES NO (hypertension), cardiomyopathy, etc.?
1.2 Respiratory or lung trouble
e.g. asthma, bronchitis, persistent cough, tuberculosis, etc?
1.3 Disorder of the digestive system, gall bladder, pancreas or liver
e.g. gastric or duodenal ulcer, recurrent indigestion, hiatus hernia, rectal bleeding, YES NO piles or jaundice, etc?
1.4 Disease or disorder of the kidneys, bladder or reproductive organs,
e.g. protein in urine, kidney stones, prostatitis, cystitis, etc?
1.5 Nervous or mental disorder
e.g. epilepsy, blackouts, paralysis, anxiety state, depression or bipolar, etc?
1.6 Eye, ear, nose or throat disorder,
e.g. defective vision, loss of hearing, ear discharge, hoarseness, etc?
1.7 Disorder or disease of skin, muscles, bones, joints, limbs or spine,
e.g. rheumatism, arthritis, gout, slipped disc or other back trouble, etc?
1.8 Diabetes, sugar in urine, thyroid or other glandular or blood disorders, cancer, growth or tumour of any kind?
1.9 Any tropical disease
bilharzia or malaria, etc?
1.10 Any other illness, disorder, operation, disability or accident relating to yourself or any other of your dependants?
1.11 Any specialist dental treatment
e.g orthodontic, periodontic, prosthodontic or maxillo-facial procedures or treatment for impacted wisdom teeth?
1.12 Are your and your dependants’ teeth and mouth cavity healthy
If NO, please state full details below.

Please supply further details below:

Required as you have answered YES (or no ito 1.12) to any of the questions above
Name and telephone no. of attending doctor or hospital
Name and telephone no. of attending doctor or hospital
Name
Telehphone No.
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Part 2: Health questionnaire and declaration

2. Tests and examinations (mainly relating to the past 12 months)
Have you or any of the dependants for whom you are applying for membership suffer from, been examined for, been tested for or have you ever had, any of the following? If YES, please state full details of each instance in the schedule following question 2.7.

Section

2.1 HIV/AIDS or an AIDS-related condition?
2.2 Any sexually transmitted disease, including hepatitis B?
2.3 If not already stated, have you or any of the dependants during the past 12 months
- had any X-rays, ECGs, other examinations or operations, or been hospitalised?
- taken any course of sedatives, tranquillisers or drugs for medical or other reasons? Please state present or past medication, dosage and reason for use.
- consulted any doctors or specialists, including regular general check-ups?
2.4 Recurrent headaches, colds, faintness, dizziness or any similar conditions?
e.g. protein in urine, kidney stones, prostatitis, cystitis, etc?
2.5 Planning to undergo any form of medical treatment in the near future?
e.g. epilepsy, blackouts, paralysis, anxiety state, depression or bipolar, etc?
2.6 Received advice, counselling, treatment or consultattion for alcoholism or drug dependency?
e.g. defective vision, loss of hearing, ear discharge, hoarseness, etc?
2.7 Been involved in an MVA (motor vehicle accident), sustained an injury on duty or contracted a work-related disease?
e.g. rheumatism, arthritis, gout, slipped disc or other back trouble, etc?

Please supply further details below:

Required as you have answered YES to any of the questions above
Name and telephone no. of attending doctor or hospital
Name and telephone no. of attending doctor or hospital
Name
Telehphone No.
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3. Your usual Medical Attendant(s) details:

4. Regular, on-going Medication:
Have you or any of the dependants taken any medication prescribed on an ongoing or a recurrent basis in the last 12 months?

Regular, on-going Medication Details

Treating doctor’s name and telephone number
Treating doctor’s name and telephone number
Name
Telephone Number
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5. For female applicants/dependants only

Do you have or any of your dependants have or had any disorder and/or symptoms of the female organs(breast, ovaries, uterus) abnormalities of pregnancy or confinement
Is any female beneficiary in this application currently pregnant or is pregnancy suspected?

6. Previous medical aid membership

Do you have previous medical aid membership(s)?

6. Previous medical aid membership details

Duration of membership(s)

Maximum file size: 8MB

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7. Employer Details

8. Permission and Declaration by applicant/new member

I (full name and surname of the member) declare and warrant that this Personal Statement is complete and true and furthermore that I understand and agree that this statement and any other relevant documents shall be the basis of the proposed eligibility for benefits from SEDMED.

I understand that my membership may be terminated retrospectively and my claims processed to date may be reversed if it is found that I have made a false declaration. Should membership be terminated retrospectively and if no claims were processed and paid on behalf the member for the relevant period, all contributions will be refunded to the member and/or employer group.

I hereby irrevocably authorise and request any medical practitioner, person or institution that is in possession of or may at a later stage obtain information (including results of any blood tests) regarding my physical and mental health/habits or those of any of my dependants, to disclose such information to SEDMED – also after my death.

I agree that the existing Rules of SEDMED, and amendments thereof, where applicable, are binding on me.

SEDMED will keep my information and the information about those whom I apply for confidential. SEDMED may only share my personal and health information or the information of any dependant if it is requested by a third party who I have already given my consent to for the disclosure of this information. If SEDMED wants to share my information for any other reason, they will do so only with my permission.

Personal Information
I consent to SEDMED having access to and processing my and my dependants’ personal information. I understand that personal information includes, amongst others, information about race, gender, sex, pregnancy, marital status, age mental health, well being, disability, culture, language, etc. I understand that processing of information means the lawful and reasonable automated or manual activity of collecting, recording, organising, storing, updating, distributing, and removing or deleting of personal information to ensure that such processing is adequate, relevant and not excessive given the purpose for which it is processed. I understand and accept that our personal information may be processed by the Scheme:

  • for verifying the accuracy, correctness and completeness of any information provided to the Scheme in the course of processing an application for membership or providing services related to our membership;
  • for the administration of my membership and benefits;
  • for providing any managed care services that me or any of my dependants;
  • for providing relevant information to a contracted third party who needs information to provide a healthcare service to me or any of my dependants;
    for profile and analyse risk to SEDMED;
  • to share our personal information with external health and service providers for them to assess or evaluate certain clinical information, in the event that we are subject to such a clinical assessment.

I further understand that I have the right to know what personal information the Scheme holds about me and my dependents and if I wish to receive this information I can request the same by completing a PAIA Form to Request Access to Records. I further understand that if I believe that the Scheme or any of its third party service providers or administrators have used our personal information contrary to the stipulations contained in this privacy statement, I may lodge a complaint with the Scheme Complaints Committee. I am aware that the process for submitting a complaint with the Sedmed Complaints Committee can be found on the website of the Scheme at www.sedmed.co.za If I am not satisfied with the outcome of the Sedmed Complaints Committee process, I may lodge a complaint with the Information Regulator at: The Information Regulator, 27 Stiemens Street, JD House, Braamfontein, PO Box 31533, Braamfontein, 2017, Tel: +27 10 023 5207, [email protected]

Section

Signed at
this
day of
20

Maximum file size: 2MB

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Note: Sedmed will not process an application for membership if the Application Form is incomplete or if all the required documents have not been provided.