Tiger Brands Medical Scheme - TBMS

1 Tiger Brands Medical SchemeRegistered in terms of the Medical schemes Act (No. 131 of 1998)DDMMYYYYNew applicationNew dependantName of individual:Inception/Start date:Name of company:Membership number:Please tick the relevant block: (The option selected determines the amount of Routine Care you have decided is required by your family. Options may be changed once a year in January only. Please refer to your benefit brochure for more detail).Level ALevel BMZANSIL evel CPlease attach a certificate of membership from the previous Medical Aid Scheme (s) to this applicationSelected Doctor name for Mzansi Option onlyPage 1 of 6 Name of General Practitioner/SpecialistPractice numberTelephone numberNumber of years consultedCode ( )Code ( )Code ( )Code ( )Registered office: Universal House, 15 Tambach Road, Sunninghill Park, SandtonPrivate bag X131, Rivonia, 2128 Tel: 0800 002 636 | Email: 1: EMPLOYER DETAILSName of employer:Contact person:Postal address:Post codeE-mail address:Telephone details:Tel: Code ( )Cell:Fax: Code ( )SECTION 4: Medical HISTORY QUESTIONNAIRE: TO BE COMPLETED BY EMPLOYEES AND THEIR dependants ELECTING TO JOIN THE Scheme AFTER THREE MONTHS OF JOINING THE COMPANYYe sNoName of & vascular SystemHigh blood pressure; high cholesterol; angina.

2 Heart attack; angiogram, previous coronary artery bypass; rheumatic fever; heart murmurs; valve problems/replacement; arrhythmias insertion of pacemakers; heart failure; stroke; varicose veins; DVTs (deep vein thrombosis); pulmonary ; emphysema; chronic bronchitis; TB; chronic infections - bronchitis & System, Gallbladder; LiverDyspeptic disease (heartburn; hiatus hernia; peptic ulcers; reflux); irritable bowel syndrome (spastic colon; inflammatory bowel disease Crohn s & ulcerative colitis; chronic diarrhoea/constipation); gallstones & jaundice; hepatitis; pancreatitis; haemorrhoids; incontinence; bowel SystemPersistent headaches; epilepsy; paralysis; degenerative diseases Alzheimer s; Parkinson s; multiple sclerosis; stroke; neuralgias; ADD (attention deficit disorder).It is most important that the questions on the following page be answered as thoroughly as possible.

3 The answers to these questions will be treated as confidential. It is important to note that any Medical condition, of which you are aware, and which is not disclosed in this application, can be excluded from benefits. Please advise whether you or any of your dependants suffer from, or have suffered from, or received treatment/consultation for any of the following conditions. Please ensure that you underline the appropriate condition, tick and complete the appropriate block/s. Underwriting will be 2: PRINCIPAL MEMBER DETAILSS urname:First name(s):Title:Marital status:Race:Present age:Nationality:Gender: M FDate of birth:Identity address:Post codePhysical address: Post codeE-mail address:Telephone details:(W) Tel: Code ( )(W) Fax: Code ( )(H) Tel: Code ( )Cell:Occupation:Date employed:Mzansi only Monthly Earnings (all income including salary, commission, fringe benefits, interest, dividends etc):(excluding bonus, overtime and travel reimbursement)RSECTION 3: DEPENDANT DETAILS (INCLUDING SPOUSE/PARTNER)NoGenderRaceFirst name/s & SurnameIdentity in Income 2 of 6 Page 2 of 6If any of the questions on this page have been answered yes, please supply details below.

4 If there is not enough space, please attach an additional 3 of 6 Page 3 of ; Muscle & JointsArthritis; rheumatism; gout; back or neck problems; fibromyalgia; previous fractures; deformities; degenerative muscle disease; osteoporosis; previous amputations/artificial limbs; birth defects; joint TractInfections; stones; albumin/blood in urine; urinary incontinence; prolapsed SystemMenopause; female hormone replacement; irregular menses; infertility; breast tumours (benign/malignant); ovarian tumours; cysts; prolapsed uterus/ Genital SystemProstate problems (hypertrophy/cancer or infections); infertility; hernias groin; scrotal swellings; testicular tumours; abnormalities of the active thyroid; diabetes mellitus; Cushing s syndrome; Addison s disease; pituitary gland ; bleeding disorders (haemophilia); leukaemia; Hodgkin s , Nose & ThroatAllergies (rhinitis, sinusitis); chronic infections (otitis, tonsillitis); nasal reconstruction; snoring; sleep apnoea; deafness hearing vision; birth defects; degenerative disease (glaucoma; retinitis pigmentosa; cataracts; keratoconus); allergies pterygiums; anticipated/previous laser surgery; artificial (psychological, psychosomatic problems)Depression; bipolar disorder; anxiety; stress; previous treatment for post traumatic stress syndrome; eating disorders bulimia & anorexia; mental retardation; alcoholism; drug Tropical DiseasesSexually transmitted diseases; genital warts; HIV/AIDS; hepatitis; ME-Virus (Yuppie Flu); malaria; bilharzias; cholera; DisordersAcne; eczema; psoriases; lesions; skin rashes; shingles; kaposi sarcoma Tissue DisordersSystemic lupus erythromatosis.

5 & GumsImpacted molars (wisdoms); previous/current orthodontic treatment; braces; crowns; recurrent infections - ; growths; tumours of any you or any of your dependants allergic to any specific type of medication ( penicillin, aspirin, sulphas, morphine, NSAIDS); pollen dust; animals; specific food types ( nuts). TreatmentHave you or any of your dependants ever had or expecting to undergo an organ treatment transplant? Have you or any of your dependants ever suffered from any condition requiring Immunosuppressive treatment? you or any of your dependants ever received any form of physiotherapy, occupational therapy or chiropractic treatment? you or any of your dependants pregnant? If yes - how many weeks? Please give expected date of you or any of your dependants had any previous or pending claims for which any other party may be liable MVA (Motor Vehicle Accident) claims?

6 If yes, please give you or any of your dependants expecting to undergo any Medical treatment, hospitalisation, operation, specialised dentistry etc, within the next twelve months? you or any of your dependants have a chronic condition requiring ongoing medication?If yes, please give the name and dosage of all the medication you or any of your dependants are currently taking. Remember to apply separately for the approval of chronic you or any of your dependants ever received any Medical attention of any nature, , hospitalisation, operation, specialised dentistry etc, not mentioned above? you or any of your dependants ever appeared before a Medical board in view of early retirement and declared medically unfit?Ye sNoName of member/dependantSECTION 4: Medical HISTORY QUESTIONNAIRE: TO BE COMPLETED BY EMPLOYEES AND THEIR dependants ELECTING TO JOIN THE Scheme AFTER THREE MONTHS OF JOINING THE COMPANY (continued)NoMember/DependantFull details of the disorder, consulting doctor, type of medication and dosage usedDate of treatmentDegree of recoveryPage 4 of 6 Page 4 of 6 SECTION 5: PREVIOUS MEMBERSHIPP lease attach a certificate of membership (from the previous Medical Scheme ) to this application.

7 Applicants wishing to join at a date after date employment by Tiger Brands need to supply certificates of membership covering at least the previous two years (see Section 9 for more information). All applicants over age 35 need to supply certificates of membership covering the period since 1 April of previous Medical Scheme /sMembership numberDate joinedDate terminatedSECTION 6: CLAIMS PAYMENT DETAILSE lectronic Transfer of payments to you and collection of member s portion, where code:Account number:Name of account holder:Name of bank:Branch:Type of account:CurrentSavingsTransmissionAuthor ised signatureDISCLAIMER: It is the member s responsibility to advise the administrators in writing of any change in banking details. Neither the Scheme not its administrators will be held liable should an incorrect account be credited under any Tiger Brands Medical Aid Scheme , hereafter referred to as the Scheme , confirms that your and your dependants personal details and Medical information shall be kept confidential and the Scheme shall take all reasonable steps to comply with the provisions of any legislation applicable to the protection of your and your dependants personal The Scheme confirms that your and your dependants identifiable information (personal and health information)

8 Will neither be used for purposes of related company business nor sold for commercial The Scheme confirms that it has data security measures in place, including restricted access to your and your dependants data, data back-up systems and data recovery The Scheme shall take all reasonable steps to ensure that all staff within the Scheme and all third parties who have access to beneficiary information for the purpose of data transfer and management, Scheme administration, managed care agreements and compliance with applicable legislation, keep the personal information of beneficiaries confidential and comply with applicable The Scheme confirms it has granted access to certain persons within the Scheme and its contracted third parties to your and your dependants personal and health information. The use of relevant personal information and/or personal health information provided is for the following purposes: verifying your identity; processing your application for membership; administration of your Medical Scheme membership; membership verification and eligibility checking; assessment, processing and reimbursement of claims for Medical expenses; determining your entitlement to benefits; underwriting or risk assessments; providing relevant information to a healthcare provider who requires this information to provide a healthcare service to you or any of your dependants ; providing managed care services to you or any of your dependants ; sharing your information with service providers, including electronic switching houses, for the purpose of processing it and rendering services to you such as electronic submission of claims to us; risk management practices.

9 Fraud prevention and detection, audit and record keeping purposes; compliance with applicable legal and regulatory requirements; population of the beneficiary registry as required by the Council for Medical schemes and the Department of Health; collection of monies owed by you or healthcare providers to us; statistical analysis (this will always be on an anonymous basis, which means that data about you that is relevant to the analysis is used but it is not linked to your name or membership number).6. In the event of a breach of confidentiality, the Scheme shall assume responsibility if the Scheme is at fault and will manage the breach according to its internal protocols and disciplinary The Scheme will ensure that underwriting is applied to all members in a consistent and equitable 7: Tiger Brands Medical AID Scheme DECLARATIONPage 5 of 6 SECTION 8: MEMBER ACKNOWLEDGEMENT AND DECLARATIONP lease read the declarations below carefully.

10 These contain acknowledgements of fact that may impact on your rights. These declarations must be read in conjunction with the rules of Tiger Brands Medical Aid Scheme (hereafter referred to as the Scheme ), and the Medical schemes Act No. 131 of 1998 (hereafter referred to as the MSA ), and all these provisions shall be binding on you and your dependants . Please tick the boxes to acknowledge that you have read each declaration:1. I, the undersigned hereby apply for membership of Tiger Brands Medical Aid Scheme and agree that all answers and information contained in this application completed by me or by any other person / s will be the basis of the proposed I warrant that the contents of this application are true, correct and complete. No cover will be granted unless Tiger Brands Medical Aid Scheme specifically notifies me in writing of their acceptance of the risk, or on receipt of a valid membership card.