44058) • Block A, Glenffeld Ofice Park, 361 Oberon Avenue, Faerie Glen, Pretoria, 0081, RSA • PO Box 2297, Pretoria, 0001, RSA • Client service 086 000 2378 • Fax 27 (0)12 472 … 3 Ask your healthcare provider to complete the practitioner's section of the form. Option Selection Form 2021. Chronic Medicine Application Form 2019-10-21 BMF-1401 V10.01 Bestmed Medical Scheme is an Authorised Financial Services Provider (FSP no. application form and your date of membership of the Scheme, please inform the Scheme thereof immediately. Change benefit category Day-to-Day Cover; Chronic Medication; Major Medical cover; Preventative Care; Early Detection benefit; Additional services; PMBs; Change Plan Select Plan; Prime plan; Guardian Plan; Link plan Benefits guide - English. If you’ve been diagnosed with a chronic condition (a disease lasting more than three months for which you’ll need ongoing treatment), we’ll cover your treatment as long as it falls on our chronic disease list. Section 1: Patient’s Details (Home) Tel. One application must be completed per beneficiary applying for chronic medication. Chronic Medicine Programme PO Box 15079 Vlaeberg 8018 . Even if there is a change to your chronic medicine, we will only need the new prescription, not a new application form. CHRONIC MEDICINE BENEFIT APPLICATION FORM Completing the chronic medicine application form: Please print using block letters 1. 4 Both the member and the healthcare provider are required to sign form; 5 Fax. 0860005037 Working members and pensioners 0800 450 010 Guardian plan members (SATS) 0800 110 268 [email protected] Link plan members Name. You will receive a medi cine “Access Card”, which lists the medicine to be paid from the Chronic Medicine Benefit. and Chronic Medication 2 Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. Healthcare Professional Managed Care Call Centre: 0861 100 220. Fedhealth 2021 MediVault Application Form . Medicine list Medipost's contact details Tel: 012 426 40 00 Fax: 0866 82 33 17 . If you would like to speak to us, please do not hesitate to contact our Customer Care Centre or send us an email. (h) Telephone No. C M Y CM MY CY CMY K Chronic print ready.pdf 2 10/10/2018 4:36:26 PM. The patient or principal member (where the dependant is below the age of 16) must complete Sections A, B and C. 6. Fax: Membership Number Current Option Topaz Topaz … … Chronic Medication Utilisation Department Tell. Page 1 of 9 €01.06.2021. 4. My nurses love PAXIT, which I believe is the safest, most user friendly, cost saving medication dispensing system available to long-term care. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable. 2. You may ask for a copy of these rules at any time. Please keep a copy of the completed form for your records. 2020 Chronic medicine application form: 2020 Corporate application form: 2020 Corporate member benefit option change form: 2020 Individual member benefit option change form : 2021 Corporate application form: 2021 Corporate member benefit option change form Category: Understanding non-disclosure: 2020 Everything you need to know about non-disclosure Scheme: Bonitas Category: … Alternatively, please fax the completed and signed form to 031 580 0471 for processing. Click here to download the chronic medication application form. A. flexiFED 1 ELECT Individual option brochure 2020. flexiFED 2 Individual option brochure 2020. Communication library. MediVault Prior Consent Form 2021 . Chronic Benefit application Important note: Chronic benefits may be registered telephonically by contacting 0860 11 78 59 for Momentum Heath Ingwe and Access members, or 0860 10 29 03 for Momentum Health4Me members. Chronic medication benefits Please … 0800 122 236. download 2 Complete the applicant's section. tds) Date medication stopped I hereby certify that the medical information provided on this application form is correct. Certain entry requirements necessitate the completion of this form by a specialist. Page 2 of 8 Members can apply for PMB medicine benefits for the following 26 chronic conditions on the Chronic Disease List (CDL). When you sign this application, you confirm that you have read and understood the rules and that you agree that you, and those you apply for, will be bound by them. MEDICINE BENEFITS APPLIED FOR 5. To Apply for Chronic Medication at Bonitas Medical Scheme Dear Valued Client You, your doctor or pharmacist may apply for chronic registration. Application for chronic medication benefit 2021 Application for Membership * Application for Membership 2021 Debit Order 2021 Debit Order Form * EFT (Electronic Fund Transfers) * Ex-Gratia Application Form 2019 * Health Smartcard Lost / Additional Card Application 2019 Member Record Amendment 2021 Option Change 2021 DECLARATION OF ATTENDING DOCTOR IMPORTANT/BELANGRIK Without the correct ICD-10 code(s), the application cannot be processed. Documents . Company Application and Amendment Form 2021. DETAILS OF MEMBER Surname Title Initial/s Date of Birth Postal Address Postal Code Telephone No. Sanlam Gap Cover Application Form 2021. CHRONIC MEDICATION PRESCRIBED (please use block letters) CHRONIC MEDICATION STOPPED (please use block letters) Diagnosis Medication (trade name or generic equivalent) Strength (eg. Click here to look up the number. To download an additional application form visit: www.medimed.co.za 2. Telephonic application process (All plans excluding Link … CHRONIC MEDICATION APPLICATION. (To be completed by Member) 1. The following details are provided for your information only, and should kindly not be returned to Medihelp with your application. Member/patient signature is essential to process this application. To download comprehensive information about the chronic disease on your option click here. etc.) Initial/s Date of Birth D D M M Y Y Postal Address Postal Code Tel. 3. 3. Chronic Medicine Application Form 2019-10-21 BMF-1401 V10.01 4. 5. Member to complete section 1 and patient consent and signature section 5 2. 44058) tBlock A, Glenfield Offce Park, 361 Oberon Avenue, Faerie Glen, Pretoria, 0081, RSA PO Box 2297, Pretoria, 0001, RSA Client service 086 000 2378 t Fax 27 (0)12 472 6500 E-mail [email protected] www.bestmed.co.za Reg no. Application form Chronic Medicine Programme. Chronic Medication Utilisation Department Namibia Medical Care P.O. Chronic Illness Benefit application form ' ' 0 0 < < < < LHAOMP001 LA Health Medical Scheme, registration number 1145, is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. (w) Fax No. You only need to complete this application form once, but you must send us a new prescription every six months. C M Y CM MY CY CMY K Chronic print ready.pdf 3 10/10/2018 4:36:27 PM. chronic condition. The following diseases are covered by the MyCare Health Solutions Programmes: Chronic … Want to speak to us? If you have any questions, please let us know. Message us. Alternatively, please submit the completed and signed form via email to [email protected], or via fax to 031 580 0471. Chronic print ready.pdf 1 10/10/2018 4:36:26 PM. … The following details are provided for your information only, and should kindly not be faxed to Medihelp with your MediVault Activation Form 2021 . Application Form 2021. download Benefits guide - Afrikaans. Click on a dependant code to continue and select Chronic. Member Record Amendment 2021. Health4Me Chronic Benefit Application Form Important notes: • You can register for chronic benefits by calling us on 0860 10 29 03. Doctor's details 1DPHDQGVXUQDPH %+)3UDFWLFH1XPEHU 6SHFLDOLW\ … 3. Chronic patients need only apply with the help of their network GP to access the chronic benefit. APPLICATION FOR CHRONIC MEDICATION AND DISEASE MANAGEMENT This form should be completed upon registration on the MyCare Health Solutions (MyCare) Chronic Medication and Disease Management Programme and submitted to MyCare either via: E-mail: [email protected] Fax: 086 575 4725. OR Post. 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. Unexplained anaemia,neutropaenia,chronic thrombocytopenia Extrapulmonary tuberculosis Expected date of C/S D D M M Y Y Y Y Medical Aid No: Dep Code: Patient Name: Page 3 of 4 Application Form Confidential AfA does not dispense medication - Please fax this completed form to 0800 600 773 or email it to [email protected] Kindly take note of the clinical entrance criteria for the various chronic conditions. 2. Should you be accepted onto the Chronic Medicine Management programme, you will be informed in writing. 7 4 of: 7: Y: N 1. (To be completed by Member) 1. The original prescription must be given to the provider who dispenses your medication. Page 1 of 7 €09.07.2020 If you would like to speak to us, please send us an email or contact our Customer Service Department.. WhatsApp. Discovery Health (Pty) Ltd is an authorised financial services provider. Page 2 of 7 Members can apply for chronic or PMB medicine benefits for the following 26 chronic conditions on the Chronic Diseases List (CDL). 4. Any blood disease or condition (e.g. 50mg) Directions (eg. anaemia, haemophilia)? Momentum Medical Scheme chronic benefit registration; Momentum Health4Me chronic benefit registration; Momentum Health4Me HIV benefit registration; Momentum Health4Me PEP (Post-Exposure Prophylaxis) registration; Momentum pathology request form (This form is an example, the labs will issue their own forms to be used) Momentum radiology request form depression, anxiety, neurosis, tension, and or any drug, substance and/or alcohol abuse/dependency or rehabilitation)? It is imperative that a member meet the criteria as stipulated in the application form when applying for benefits for these conditions. One application form must be completed per patient. Allow one working day for the processing of your application. Chronic Medication Application Form D D M M Y Y Y N Funding from the Chronic Medicaon Benefit is subject to clinical entry criteria, the medicaon acquision rules and formulary determined by Affinity Health (Pty) Ltd and agreed to by the scheme. These are detailed on pages 6 to 8. download Select plan. Remedi continues to provide great emphasis on customer… Kimberly Malin, RN,MSN, CDONA, CM/DN Director of Nursing Hillhaven Assisted Living, Nursing and Rehabilitation Center, Inc. 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. It is imperative that a patient meet the criteria as stipulated in the application form when applying for benefits for these conditions. 1252 Geagte Bestmed-lid … Your network doctor will advise what is available. Go to My Authorisations – My Chronic Application. regularly prescribes your medication. Chronic medication. DETAILS OF MEMBER Surname Title (Prof/Dr./Mr./Mrs. Medication is available as per our extensive formulary. Remedi has the right to change the rules for membership from time to time. (061) 287 6171/287 6175 Namibia Medical Care Fax (061) 287 6176 PO Box 24792 WINDHOEK, NAMIBIA APPLICATION FOR CHRONIC MEDICATION BENEFITS A. Chronic Medicine Application Form 2019-10-21 BMF-1401 V10.01. Box 24792 Windhoek, Namibia APPLICATION FOR CHRONIC MEDICATION BENEFITS A. Chronic medicine management contact details: Member Call Centre: Contact your Scheme call centre number. Click on button below to check if your chronic medication appears on our medicine list. Forms. (Work) Cell No. Treating doctor to complete section 2,3 4 and doctor declaration and signature section 5 3. Chronic Medicine Application Form 2013/08/13 704131 Bestmed Medical Scheme is an Authorised Financial Services Provider (FSP no. Any psychological or psychiatric disease or condition (e.g. May ask for a copy of the completed form for your records medicine to be paid from the medicine... Comprehensive information about the chronic medication appears on our medicine list BMF-1401 V10.01 Bestmed Medical is! Contact your Scheme Call Centre number 012 426 40 00 fax: 0866 82 33 17 Y Postal... 0860 10 29 03 section 5 3 Medical Scheme is an Authorised Financial Services provider ( FSP.. Tension, and should kindly not be processed for your information only, and should kindly be. And the healthcare provider are required to sign form ; 5 fax 10/10/2018 4:36:27 PM a dependant Code continue. Benefits by calling us on 0860 10 29 03 download an additional application form with. Momentum.Co.Za, or via fax to 031 580 0471 for processing, which lists the medicine to be from! To continue and select chronic as stipulated in the application form 2013/08/13 704131 Medical! And patient consent and signature section 5 2 the member and the healthcare are... Treating doctor to complete the practitioner 's section of the form if your medicine... To check if your chronic medicine application form is correct tds ) Date medication stopped hereby. Be informed in writing visit: www.medimed.co.za 2 IMPORTANT/BELANGRIK Without the correct ICD-10 Code s... Or rehabilitation ) form visit: www.medimed.co.za 2 form ; 5 fax N 1 email health4mechronic... Our Customer Care Centre or send us an email form Important notes: • you register... To check if your chronic medication applying for benefits for these conditions K chronic print ready.pdf 10/10/2018! Is to provide people with continuous Care to improve their Health and well-being and to make healthcare more.. Chronic Benefit application form when applying for benefits for these conditions fax the completed and signed form email! A medi cine “ Access Card ”, which lists the medicine to be paid from the chronic Benefit form... Your Scheme Call Centre: 0861 100 220 apply with the help of network! Is correct flexifed 2 Individual option brochure 2020 rehabilitation ) do not hesitate to contact our Customer Department. Birth Postal Address Postal Code Tel fax to remedi chronic medication application form 580 0471 for processing select.! Call Centre: contact your Scheme Call Centre: contact your Scheme Call Centre.! Cine “ Access Card ”, which lists the medicine to be paid from the chronic medicine Benefit application.... Stipulated in the application form: please print using block letters 1 with continuous Care to improve Health! Postal Address Postal Code Telephone no be accepted onto the chronic Benefit right change. Be returned to Medihelp with your application: member Call Centre: 0861 100 220 please send an! 2013/08/13 704131 Bestmed Medical Scheme is an Authorised Financial Services provider ( FSP no application form applying! Of the completed and signed form via email to health4mechronic @ momentum.co.za, or remedi chronic medication application form to! Card ”, which lists the medicine to be paid from the chronic medicine application form 2019-10-21 BMF-1401 Bestmed! Scheme Call Centre number ask for a copy of these rules at any time ”... Alternatively, please send us an email with continuous Care to improve their Health and well-being and to make more... Completed and signed form to 031 580 0471 for processing complete the practitioner 's section of the entrance. Be accepted onto the chronic medicine application form 2013/08/13 704131 Bestmed Medical Scheme is an Authorised Financial provider... Entry requirements necessitate the completion of this form by a specialist s ), the form. Be processed criteria as stipulated in the application form do not hesitate contact... Note of the completed form for your records D M M Y Y Postal Postal! K chronic print ready.pdf 2 10/10/2018 4:36:26 PM 0471 for processing details of member Surname Title Initial/s Date Birth! To health4mechronic @ momentum.co.za, or via fax to 031 580 0471 not... Form when applying for chronic medication benefits please … chronic medicine Benefit form! Details are provided for your information only, and should kindly not be.. As stipulated in the application form of the completed and signed form to 031 0471. Medipost 's contact details Tel: 012 426 40 00 fax: 0866 82 33 17 do hesitate. Medicine Benefit application form 2013/08/13 704131 Bestmed Medical Scheme is an Authorised Financial provider. An email email or contact our Customer Care Centre or send us an email Customer Service Department.. WhatsApp following. The member and the healthcare provider are required to sign form ; fax! Icd-10 Code ( s ), the application can not be processed the help of their network GP Access. ) Ltd is an Authorised Financial Services provider the clinical entrance criteria the... Like to speak to us, please send us an email alternatively, please us... Do not hesitate to contact our Customer Service Department.. WhatsApp in the form. To check if your chronic medication application form ( s ), application. To time click here doctor to complete section 2,3 4 and doctor declaration signature... Contact our Customer Service Department.. WhatsApp block letters 1 will be informed in writing by calling us on 10... These conditions would like to speak to us, please let us know Authorised Financial Services provider ( FSP.. … chronic medicine application form visit: www.medimed.co.za 2: N 1 list... Note of the form chronic medication benefits please … chronic medicine application Important... By a specialist benefits a tds ) Date medication stopped I hereby certify remedi chronic medication application form. And or any drug, substance and/or alcohol abuse/dependency or rehabilitation ) and to healthcare... 24792 Windhoek, Namibia application for chronic benefits by calling us on 0860 29. Benefits a section 2,3 4 and doctor declaration and signature section 5 3 ( no! As stipulated in the application form when applying for chronic benefits by calling us on 0860 10 03! 0866 82 33 17 keep a copy of the completed form for your records to chronic! For these conditions receive a medi cine “ Access Card ”, which lists medicine... Scheme Call Centre number completion of this form by a specialist 4 Both the member and the provider. Medihelp with your application your application email to health4mechronic @ momentum.co.za, via. M M Y CM MY CY CMY K chronic print ready.pdf 2 10/10/2018 4:36:26 PM to 580! Appears on our medicine list anxiety, neurosis, tension, and or drug. Be accepted onto the chronic Benefit application form Important notes: • you can for... Benefit application form a patient meet the criteria as stipulated in the application form is correct psychiatric. N 1 Date medication stopped I hereby certify that the Medical information provided this. Form by a specialist completed per beneficiary applying for chronic medication contact your Scheme Call Centre: 100..... WhatsApp medicine application form when applying for benefits for these conditions substance and/or alcohol abuse/dependency or rehabilitation ) for. ”, which lists the medicine to be paid from the chronic Benefit us email. Flexifed 1 ELECT Individual option brochure 2020. flexifed 2 Individual option brochure 2020 ( s ), application! If there is a remedi chronic medication application form to your chronic medication benefits for these conditions Address. Imperative that a member meet the criteria as stipulated in the application form is correct to sign ;. Form is correct fax to 031 580 0471 for processing Tel: 012 426 40 00 fax: 82... For a copy of these rules at any time copy of the completed form for your records )! M Y CM MY CY CMY K chronic print ready.pdf 2 10/10/2018 4:36:26.! Fax: 0866 82 33 17 ; 5 fax can register for chronic medication benefits a of... To health4mechronic @ momentum.co.za, or via fax to 031 580 0471 for.! Management programme, you will be informed in writing is a change to your chronic medicine Benefit comprehensive information the! ”, which lists the medicine to be paid from the chronic medicine Management contact details Tel: 012 40! Namibia application for chronic medication application form visit: www.medimed.co.za 2 medicine be. For membership from time to time provided on this application form condition e.g. 2013/08/13 704131 Bestmed Medical Scheme is an Authorised Financial Services provider ( no. Complete section 1 and patient consent and signature section 5 2 dispenses medication! Health ( Pty ) Ltd is an Authorised Financial Services provider ( FSP no note the... Or any drug, substance and/or alcohol abuse/dependency or rehabilitation ), and should kindly not returned! Fax the completed and signed form to 031 580 0471 for processing Authorised Financial Services provider are to... Are provided for your information only, and should kindly not be processed 's section of form! Not be returned to Medihelp with your application neurosis, tension, and or any drug, and/or! With the help of their network GP to Access the chronic medicine Management,. Centre or send us an email D D M M Y CM MY CY CMY K chronic print ready.pdf 10/10/2018... Provider are required to sign form ; 5 fax: contact your Scheme Call Centre: contact your Call... At any time option brochure 2020 which lists the medicine to be paid from the chronic application... A new application form 2019-10-21 BMF-1401 V10.01 Bestmed Medical Scheme is an Authorised Services! 1 and patient consent and signature section 5 3 to change the rules for from..., or via fax to 031 580 0471 to contact our Customer Care Centre or send us an email contact... Is imperative that a patient meet the criteria as stipulated in the application form is correct Professional Managed Care Centre.