MEMBER AND DEPENDANT APPLICATION FORM
NEW APPLICATIONNEW DEPENDANTName of companyName of individualDate of commencementMembership number:DDYYMMOption (please tick the appropriate box)PinnacleDynamix SymmetryMumedAxis NetworXUniSaveNetworX Option: Members are required to nominate a General Practitioner (per beneficiary) from the list of approved network service nameName of nominated GPAddress of nominated GPGP practice numberGP telephone numberMumed / NetworX applications Copy of 3 latest salary slips, IRP 5 or IT 34Membership certificate / s from previous medical aid / sAdult DEPENDANT 21 years and over Proof of registration / Affidavit of dependencyCopy of Identity Documents / copy of passportProof of adopted / Foster / Child status legal documentsPLEASE ATTACH CERTIFICATES OF MEMBERSHIP FROM THE PREVIOUS, MEDICAL SCHEME / S TO THIS APPLICATIONMember number Company code Persal number Code Race (for statistical use only)Language Subs tableMEMBER AND DEPENDANT APPLICATION FORMCHECKLIST DOCUMENTATION TO ACCOMPANY THIS APPLICATIONFOR OFFICE USE ONLYPage 1 of 6Pinnacle Efficiency DiscountDynamix Efficiency DiscountSymmetry Efficiency DiscountMumed Efficiency DiscountAxis Efficiency DiscountNetworX Efficiency Discount(please complete schedule below)(please complete schedule below)Universal House, 15 Tambach Road, Sunninghill Park, SandtonPO Box 1411 Rivonia 2128Tel: 0861 222 777E-mail: Website: by Universal Healthcare Administrators (Pty) LtdCompCare Wellness Medical Sc
NEW APPLICATION NEW DEPENDANT Name of company Name of individual Date of commencement Membership number: D D M M Y Y Option (please tick …
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