Prescribed Minimum Benefits out-patient …

1 Page 1 of 2 Discovery Health (Pty) Ltd administers the Discovery Health Medical Scheme Registration number 1997/013480/07 An authorised financial services providerTitle Initials Surname ID number or passport number Date of birth YYYYMMDDM embership number Postal address Code Telephone (H) (W) Cellphone Fax Email May we communicate your confidential information to you by email? Yes F No F or fax? Yes F No FPrescribed Minimum Benefits out-patient application formContact usTel: 0860 99 88 77, PO Box 784262, Sandton, 2146, s name and surnameMembership numberHow to complete this application form1. About the main member (member to complete)2. About the patient (doctor to complete)1.

2 Please use one letter per block, complete with black ink and print To avoid administrative delays, please make sure this application is completed in Please complete this form for cover of out-of-hospital management of a Prescribed Minimum Benefit (PMB) You need to complete section 1 of this Your doctor must complete section 2, 3 and section 4 and include detailed documentation to support your Please fax this completed and signed form with any documentation to support this application to 011 539 2780 or email You will receive a letter informing you of our decision and the process you should 08/09 Title Initials Surname ID number or passport number Date of birth YYYYMMDDT elephone (H) (W) Cellphone Fax Email May we communicate your confidential information to you by email address Yes F No F or fax?

3 Yes F No FPage 2 of 2 Discovery Health (Pty) Ltd administers the Discovery Health Medical Scheme Registration number 1997/013480/07 An authorised financial services Application for out-of-hospital medical management*ConditionICD-10 codeRPL consultation orprocedure code**RPL descriptionQuantity per year*Please clearly specify what is required, for example consultations, pathology, radiology or specific procedure.**The RPL codes must be supplied for us to review the Application for medicineCurrent medicine required (please provide details and relevant laboratory tests to demonstrate success of therapy, for example blood pressure reading, HBA1C) ConditionICD-10 codeMedicine name, strength and dosageNAPPI codeQuantity each monthNumber of Application for radiologyConditionICD-10 codeRPL codeRPL DescriptionQuantity per Application for pathologyConditionICD-10 codeRPL codeRPL DescriptionQuantity per Previous history and current medical statusPlease attach any relevant supporting documentation, for example pathology Application (doctor to complete)4.

4 Doctor s details (doctor to complete)5. DisclaimerNamePractice numberFaxDoctor s signatureDate YYYYMMDD1. Should it become apparent that the treatment is no longer medically necessary, the Scheme may revoke cover for treatment that has been approved in terms of this The Scheme will only approve treatment that meets the requirements of the Scheme s clinical guidelines and protocols. These guidelines are based on generally accepted clinical guidelines and treatment Each case will be assessed on its own merit.