Registration for Prescribed Minimum Benefit (PMB) Chronic Disease Conditions

Once the form has been completed, press Submit. If you would like to download print, complete and fax the form, click HERE.

1. PRINCIPAL MEMBER / DEPENDANT / PATIENT DETAILS (Complete One Form per Applicant)

Surname:

First Names:

Postal Address:

Postal Code:

Telephone Number: Home

Telephone Number: Work

E-mail Address:

Medical Plan and Option:

Membership Number:

Principal Member Date of Birth:

Dependant / Patient Surname:

Dependant / Patient First Names:

Dependant / Patient Code:

Dependant / Patient Date of Birth:


2. DIAGNOSED PMB CHRONIC DISEASE CONDITION/S*
(Tick the Applicant’s diagnosed disease condition/s)
* Additional documentation may be required for pre-authorization.

Addison’s disease
Asthma
Bronchiectasis
Cardiac Failure
Cardiomyopathy
Chronic Obstructive Pulmonary Disease (e.g. Emphysema)
Chronic Kidney Disease
Coronary Artery Disease
Crohn's Disease
Diabetes Insipidus
Diabetes Mellitus
Dysrhythmia (Irregular Heartbeat)
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia (High Cholesterol)
Hypertension (High Blood Pressure)
Hypothyroidism (Inactive Thyroid Gland)
Multiple Sclerosis
Parkinson's Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus Erythematosus (SLE)
Ulcerative Colitis
Other
3. DECLARATION

I declare and understand that my application shall be null and void if any information supplied by me should be false or incomplete, in which
case I will repay all monies paid to me (or on my behalf) by the Scheme for benefits received in the treatment of any of the disease conditions
ticked above.
I give my irrevocable consent to any medical doctor, person or organization who may possess, or come into possession of any information to
disclose this information to the Scheme, if such information is required for the management of my health or the health of my dependants.