application for membership 12182018-done · adenoiditis, nasal surgery eyes conditions glaucoma,...

stamp of employer of 10

Membership number:

First name(s):(as per ID)

Surname:

Identity number:

Population group:

Postal Address:

Title:

African Coloured Indian

Initials:

Code:

Code:

Cell:Occupation:

Employer group:

Silver Saver Plan Gold Ascend Plan

Platinum Enhanced Plan

Gold Ascend EDO Plan

Platinum Enhanced EDO Plan Titanium Executive Plan

health in caring hands

APPLICATION FORMEMBERSHIP

Please use black ink to complete all sections and return as soon as possible to ensure speedy registration

SelectPlan:

FOR INTERNAL USE ONLY

SECTION 1 PERSONAL DETAILS OF PRINCIPAL MEMBER

SECTION 2 EMPLOYER DETAILS

White Asian

Physical Address:

Email:Tel (Home):

Date joining fund:

Income category:

Member’s share of contribution:

Total monthly contribution:

Employer/ account number:

NB: Proof of income/salary slip to be submitted with this form.

Name:

Email:

Tel:

Tel (Work):

Date of benefit:

Employer’s share of contribution:

Payroll/ Employee number:

Company/division:

Fax:

Designation:

Signature of employer:

I confirm that the applicant is employed and commenced employed on Date:

And that contributions are being deducted in accordance with the applicant’s income and the eligible dependants, in terms of the appropriate are being deducted in accordance with the employee’s status will be advised to the fund within seven days.

Sizwe Medical Fund is administered by 3Sixty Health (Pty)Ltd. For General Enquiries - Monday to Friday | 8am - 5amTel: 0860 100 871 Email: [email protected] Medical Fund is administered by 3Sixty Health (Pty)Ltd. For General Enquiries - Monday to Friday | 8am - 5pmTel: 0860 100 871 Email: [email protected]


Cardiovascular ConditionsHeart failure, hypertension, shortness of breath(angina), high blood pressure Respiratory ConditionsAsthma, COPD Chronic obstructive pulmonary disease, tuberculosis, bronchitis

Neurological ConditionsStroke, epilepsy, paralysis, weakness, myasthenia gravis

Grastro Intestinal ConditionsGastric/ duodenal ulcer, liver disorder, hepatitis, hiatus hernia, gal bladder stones, pancreatitis

Genito Urinary ConditionKidney stones, prostatic hypertrophy, renal failure glomerolonephros, STI’s (including HIV)

Endocrine ConditionsDiabetes insipidus, thyroid disorders, addison’s disease, diabetes mellitus, osteoporosis

Blood ConditionsAnaemia, blood clotting problems, deep vein thrombosis, leukaemia, lymphoma

Gynaecological & Obstetric ConditionsAbnormal papsmear, abnormal bleeding pregnancy, miscarriage, polycystic ovarian

Mental Health ConditionsDepression, dementia, bipolar disorder, ADHD

Musculoskeletal (back, bone, muscle pain)Arthritis, sarcoidosis, �bromyalgia, ankylosing spondylitis, sjogren’s syndrome

Tumour & GrowthsBreast lumps, cancer, abnormal papsmear, abnormal mogram results, prostate speci�c antigen (PSA)

Ear, Nose and ThroatChronic otitis media, cochlear implant, sinus problems, adenoiditis, nasal surgery

Eyes ConditionsGlaucoma, squint, blurred vision, macular degeneration, ptosis, uveitis, retinal detachment

Are you or any of your dependants expecting to have medical investigations or surgery or planning hospitalisation or treatment in the next 12 months or have you been admitted to hospital in the last 12 months?


Have you or any of your dependants received or not yet received medical advice or treatment for symptoms, not yet diagnosed by a medical professional, in the last 12 months before this application?

Have you or any of your dependants been diagnosed with or received treatment for any conditions not mentioned in the questions above in the last 12 months before this application?


CMAC 171121303

14/2 Midas Avenue, Olympus

0043

BR21401

As Sizwe Medical Fund we are required by POPIA to explain how we obtain, use, disclose and otherwise process your information, which may include health and financial information (personal information). Sizwe Medical Fund and its administrator (3Sixty Health (Pty) Ltd) will keep your information, including your personal information supplied to us in this application confidential. Acceptance of these terms and conditions is a requirement for activation and servicing of your medical scheme membership. You agree to us processing your personal information for the following purposes:

Sizwe Medical Fund is administered by 3Sixty Health (Pty)Ltd. For General Enquiries - Monday to Friday | 8am - 5pmTel: 0860 100 871 Email: [email protected]

Sizwe Medical Fund is administered by 3Sixty Health (Pty)Ltd. For General Enquiries - Monday to Friday | 8am - 5amTel: 0860 100 871 Email: [email protected]

Email completed form to [email protected] or submit to your broker.

Sizwe Medical Fund is administered by 3Sixty Health (Pty)Ltd. For General Enquiries - Monday to Friday | 8am - 5pmTel: 0860 100 871 Email: [email protected]

application for membership 12182018-done · adenoiditis, nasal surgery eyes conditions glaucoma,...

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