Transcription of MEMBER AND DEPENDANT APPLICATION FORM
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MEMBER AND DEPENDANT APPLICATION FORM
NEW APPLICATIONNEW DEPENDANTName of companyName of individualDate of commencementMembership number:DDYYMMO ption (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 34 Membership 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 APPLICATIONM ember 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 6 Pinnacle 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 2128 Tel: 0861 222 777E-mail: Website: by Universal Healthcare Administrators (Pty) LtdCompCare Wellness Medic
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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