Contact us

Tel: 0800 BANKMED (0800 226 5633) • Private Bag X2, Rivonia 2128 • www.bankmed.co.za

Application to add dependant/s 2024

This document is an application form to add your dependant/s on your Bankmed Medical Scheme membership.
It also contains some rules for your membership. Please make sure you read and understand these terms and conditions.
Who we are
Bankmed (referred to as ‘the Scheme’), registration number 1279, is a non-profit organisation, registered with the Council for Medical Schemes.
Discovery Health (Pty) Ltd (referred to as ‘the administrator’) is a separate company and an authorised financial services provider
(registration number 1997/013480/07) which takes care of the administration of your membership for the Scheme.
Purpose of the form
The information requested in this application form is required to enable the Scheme to process your membership application and to help in the
administration of your membership as well better administer the affairs of the Scheme.
How to complete this form
1. Please use one letter per block, complete in black ink and print clearly. Alternatively, complete the form digitally.
2. Read and understand the terms and conditions for membership (section 10)
3. The main applicant must sign and date any changes
4. Please attach a copy of each applicant’s identity document. E-mail application@bankmed.co.za or fax 011 539 3000
5. Provision is made in this form for you and your dependants to provide information relating to your race. This information is required by the
Council for Medical Schemes for statistical purposes only. You are not compelled to provide this information.
Once you send us your application form, the following will take place:
Should any details be missing or should we require more information for underwriting purposes, we will contact you.
We will activate your membership and send you a letter of confirmation when we are offering standard terms of acceptance. Where you
have waiting periods and/or late-joiner penalties, we will issue a counter-offer letter which will indicate any conditions applicable to your
membership. You may accept the offer by signing and returning the letter for us to activate your membership.
We will send you a welcome letter, SMS or an e-mail to let you know when your application has been fully and completely submitted. This
date may differ from the date on which you sign the application form.
You will then receive a pack in the post or this may be handed to you by your employer contact.
If you do not hear from us within seven days after submitting your application form, please contact us on 0800 BANKMED (0800 226 5633).
When you sign this application, you confirm that you have read and understood the rules for membership and agree to them.

1. Principal Member details

Membership number

ID or passport number

Member's surname

Member's name
D D M M Y Y Y Y
Cover start date

2. Regular dependant/s – only to be completed if you are adding a spouse, domestic partner, civil union partner, a
child or a dependant/s grandchild
Please notify Bankmed within 30 days of any event which alters the eligibility of your registered dependant/s, i.e. if you get divorced
or if you and your domestic partner separate/are no longer living together.
If you are registering a spouse/civil union partner, please attach a copy of your marriage certificate or proof of civil union.

If you are registering a newborn baby, please attach a copy of the birth certificate.

If you are registering a domestic partner, please complete and sign the Domestic Partner Declaration at the end of this section.

If you are registering a grandchild in respect of whom you are liable for family care and support, please complete and
sign the Grandchild Declaration at the end of this section.

If you are registering a child or grandchild who is 27 years or older, you will need to demonstrate that you are liable for his/her family care
and support in that he/she:

Please note that this form expires on 31/03/2025. Up to date forms are available on www.bankmed.co.za. BANAAD001

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 is unable to support himself/herself and is financially dependent on you for family care and support (please attach an
affidavit setting out details of his/her monthly income and your regular contribution to his/her living expenses); or

is dependent on you due to mental or physical disability (please attach a medical report); or

is a student at a registered tertiary institution and is financially dependent on you for family care and support (please attach
proof of registration or an affidavit).

“Child” means your child, stepchild, legally adopted child, foster child, or a child who has been placed (or is in the process of being placed) in
your custody or in the custody of your partner/spouse. Proof of dependence must be supplied each year for children (including grandchildren)
who are 27 years or older. Adult contribution rates apply from the time a dependent child (or grandchild) turns 23.

Race African Coloured Indian/Asian White Other Do not want to disclose

You are not compelled to provide the information required on race. The Scheme is required by the Council for Medical Schemes to collect
this data and is used for statistical purposes only.

Initial/s Surname Full name/s Date of birth Gender Monthly Relationship ID number or
income (e.g. spouse, passport number
(DD/MM/YYYY)
(compulsory) partner, (attach copy)
grandchild)

Domestic partnership declaration - only to be completed if you are registering a domestic partner

I, (your name and surname) declare that I have established a domestic partnership

with (your domestic partner’s name and surname) and that we have been living together

since (date). I declare that we intend to continue living together indefinitely, and I undertake to inform

Bankmed within 30 days in the event of termination of this domestic partnership.

Signed by me (your signature) on this day of (month) (year).

Grandchild declaration - only to be completed if you are registering a grandchild who is dependent on you for family
care and support

I, (your name and surname) declare that any grandchild included in this application is

financially dependent on me for family care and support.

Signed by me (your signature) on this day of (month) (year).

3. Special dependant/s – only to be completed if you are adding a parent, parent-in-law, parent of a civil union partner
or a brother/sister who is dependent on you for family care and support
PLEASE DO NOT cancel the existing membership of a special dependant with their current medical scheme (if applicable) before you have
received confirmation that he/she qualifies as your dependant on Bankmed.
Please complete and sign the Special Dependant Declaration at the end of this section, regarding your special dependant/s.

Race African Coloured Indian/Asian White Other Do not want to disclose

You are not compelled to provide the information required on race. The Scheme is required by the Council for Medical Schemes to collect
this data and is used for statistical purposes only.

Please note that this form expires on 31/03/2025. Up to date forms are available on www.bankmed.co.za. BANAAD001

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Initial/s Surname Full name/s Date of birth Gender Monthly Relationship to ID number or
income Principal passport
(DD/MM/YYYY)
(compulsory) Member (e.g. number (attach
spouse, copy)
partner,
grandchild)

Nephews and nieces are not eligible as dependant/s, unless they are in your foster care or legal guardianship exists (attach proof)
Grandparents do not qualify as dependant/s

SPECIAL DEPENDANT DECLARATION – ONLY TO BE COMPLETED IF YOU ARE REGISTERING SPECIAL DEPENDANT/S

I, (your name and surname) declare that any special dependant indicated in the table above is

unable to support himself/herself financially and that he/she is dependent on me for family care and support.
I declare that his/her income as declared in this application form is a true and accurate reflection of his/her regular monthly income from all
sources.
I undertake to notify Bankmed in writing should any special dependant as registered on Bankmed, no longer be financially dependent on me
for family care and support.
I accept that dependant membership of a special dependant will terminate in the event the requirements for registration as a special
dependant are no longer being satisfied.

(your signature) on this day of (month) (year).

Signed by me

I am aware that Bankmed reserves the right to impose waiting periods on any special dependant included in this application.
A three-month general and/or 12-month condition-specific waiting period (nine months in respect of an existing pregnancy) may be imposed
if:
the dependant was without medical scheme cover for three months or more, immediately preceding this application to join Bankmed
the dependant was on a previous medical scheme for less than two years and applied to join Bankmed within three months of ending
membership of the previous scheme (12-month condition-specific waiting period only)
the dependant was on a previous medical scheme for two or more years and applied to join Bankmed within three months of ending
membership of the previous scheme (three-month general waiting period only)
Bankmed will notify me in writing within one month of registration, should any of these waiting periods apply to me and/or any of my
registered dependant/s, based on the information provided in this application.
I am aware that a penalty may be added to the monthly contribution payable to Bankmed in respect of any special dependant as per this
application form, who is 35 years or older at the time of this application and was not registered as a member or dependant on a registered
medical scheme on 1 April 2001 and/or has (at any time) been without medical scheme cover for a period of three or more consecutive
months since 1 April 2001.
Bankmed will notify me in writing within one month of registration, of any penalties that may apply, based on the information provided in this
application.

Name
D D M M Y Y Y Y
Date
Signature

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4. Selecting your GP (Basic and Essential Plans only)
If you wish to receive unlimited GP visits, you must nominate a primary and secondary GP. Please place their information below. (This should
be completed by Basic and Essential Plan members only):

Name Primary GP name Practice number

Spouse or partner

Dependant/s 1

Dependant/s 2

Dependant/s 3

Name Secondary GP name Practice number

Spouse or partner

Dependant/s 1

Dependant/s 2

Dependant/s 3

5. About your employer

D D M M Y Y Y Y
Please ask your employer to complete this section. Cover start date

Name of employer Employer or billing number

Applicant's employee D D M M Y Y Y Y
Date of employment
number
Branch name Branch number

Physical address

Unit/Suite number Complex name

Street number Street name

Suburb

City Post code

Telephone Fax
Employer e-mail
address
Personnel officer

Signature of Personnel Officer Payroll Stamp

D D M M Y Y Y Y
Designation Date

6. Your banking details

6.1 Your contributions
Should you be paying your contributions in full or in part, please complete this section:
Please note: we cannot accept credit card account details.

Bank name

Branch name Branch code - -

Account number Type of account Cheque Savings

Account holder

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Account holder contact

Account holder e-mail address

If the third party bank details, please insert the third party ID number

If the third party bank account is a Joint account Company account Trust account
Please provide proof of bank account. Refer to Annexure A at the back of the application form for the proof of bank account required.
As part of Payment Association of South Africa (PASA) debit order mandate requirements, you are required to supply the account holder's
residential address, e-mail address and contact number. Please note that the details you supply will only be used for the PASA debit order
mandate requirement and will not be used to update the contact details we have on our system. If you wish to update any contact details
please visit www.bankmed.co.za.

D D M M Y Y Y Y
Date
Account holder's signature

6.2 Your claims refund

May we use the same account from which contributions are deducted in order to refund your claims? Yes No

If you do not wish to use the same banking details for your contributions and claims refunds, please provide us with the details
you wish to use:
Please note: we cannot accept credit card account details.

Bank name

Branch name Branch code - -

Account number Type of account Cheque Savings

Account holder

If we are paying a third party bank account, the Principal Member must insert the ID number of the third party.

If third party bank details, please insert the third party ID number

By signing this application, you agree that once claims have been refunded into the selected bank account, Bankmed will not be responsible in
any way for the amounts refunded.

7. Previous medical scheme details

Are your dependant/s currently on another medical scheme? Yes No
If you have ticked “Yes”, have they given notice of termination to their current medical scheme? Yes No

If “Yes”, please attach a certificate of membership from that medical scheme reflecting the end date of membership. We cannot finalise this
application without this.
If “No”, please give the required notice to the current medical scheme before submitting this application, and attach a certificate of membership
from that medical scheme indicating the end date of membership. We cannot finalise this application without this.
Please provide the details of all registered medical schemes which your dependant/s previously belonged to. We will use this information
to determine whether we need to apply any waiting periods, late-joiner penalty fees or both. Kindly supply us with proof in the form of a
membership certificate.

Please add the details of the different medical schemes that any of your regular dependant/s applying for cover belonged to:
Dependant/s Name Scheme name Start date End date if already Are they still a Reason for leaving
resigned member?
Yes No

Yes No

Yes No

Yes No

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Please add the details of the different medical schemes that any of your special dependant/s applying for cover belonged to:

Dependant/s Name Scheme name Start date End date if already Are they still a Reason for leaving
resigned member?
Yes No

Yes No

Yes No

Yes No

8. Your health questions

The spouse or partner and all dependant/s applying for cover need to complete section 8.
Have you or any dependant in this application ever experienced, been treated for, or are you currently suffering from any of the following
symptoms, conditions or disorders? We have listed some examples of conditions, symptoms or disorders under each question. These are
only examples and not the full list of conditions, symptoms or disorders.

We use this information only for lawful purposes, for example, enabling us and our administrator to process your application and to optimally
administer your membership, to verify whether the information you provide on this application form is true and complete, to provide you with
customised information relevant to your health status, to develop disease management programmes for specific conditions, to review and
enhance Scheme benefits, to improve Scheme’s financial modeling, to assist the Scheme to better assess and mitigate its risk and other
beneficial uses. A condition specific waiting period will only be imposed on your membership if you or your dependant received or were
recommended any medical advice, diagnosis, care or treatment within a within a 12-month period ending on the date on which this application is
considered to be fully and properly made.

Please include congenital abnormalities. Please take note that if you have any symptom or condition not listed in the questions
below, you should highlight and provide full details of this symptom or condition in response to question 8.18 below. Indication of
existing medical conditions on this application does not automatically enroll you/your dependants onto the Scheme’s Disease
Management programme. For more information with regards to the Schemes disease management enrollment visit
www.bankmed.co.za

8.1 Tumours, growth and disorders of the skin Yes No

Example: abnormal pap smear results, skin lesions, eczema, psoriasis, breast disease, non-cancerous tumours, cancerous tumours,
cancer of any organ, fibrocystic breast disease, fibroadenoma, lump in breast, abnormal mammogram result, abnormal PSA (prostate
specific antigen) result, abscess, any autoimmune conditions, any congenital conditions, or other skin conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last treatment
diagnosis diagnosed/symptoms symptoms, this condition and taken
consultations and/or dosage
hospitalisation

8.2 Heart and circulation conditions Yes No

Example: chest pain, palpitations, shortness of breath, coronary heart disease, angina, heart attack, arrhythmia, high blood pressure
(hypertension), cardiomyopathy, valvular heart disease or heart valve replacement, rheumatic fever, high cholesterol, previous heart surgery,
stents, pacemaker, any autoimmune conditions, and any congenital conditions, peripheral vascular disease, deep vein thrombosis,
pulmonary embolus, varicose veins.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last treatment
diagnosis diagnosed/symptoms symptoms, this condition and taken
consultations and/or dosage
hospitalisation

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8.3 Gynaecological and Obstetric conditions Yes No

Example: abnormal pap smear results, abnormal menstrual bleeding, endometriosis, miscarriage, polycystic ovarian syndrome, infertility,
ectopic pregnancy, any autoimmune conditions, and any congenital conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last treatment
diagnosis diagnosed/symptoms symptoms, this condition and taken
consultations and/or dosage
hospitalisation

8.4 Are you or any of your dependants pregnant or undergoing treatment/investigation for pregnancy? Yes No

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.5 Mental health Yes No

Example: mood disorders (depression, bipolar disorder), anxiety disorders, schizophrenia, personality disorders, sleeping disorders (i.e.
narcolepsy), eating disorders, Alzheimer’s disease, dementia, attention deficit-hyperactivity disorder, drug and/or alcohol abuse or
rehabilitation, suicide attempt, post traumatic disorders, counselling, and any other psychological conditions, any autoimmune conditions,
and any congenital conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.6 Metabolic or endocrine conditions Yes No

Example: diabetes mellitus (high blood sugar), diabetes insipidus, thyroid disease, Addison’s disease, Cushing’s syndrome, metabolic
syndrome, parathyroid disease, Paget’s disease, osteoporosis, growth deficiency, metabolic disorders, Conn’s syndrome, any autoimmune
conditions, and any congenital conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.7. Abdominal conditions Yes No

Example: hepatitis, cirrhosis, portal hypertension, liver disease, liver failure, pancreatitis, cystic fibrosis, gall bladder/stones GORD (reflux),
heartburn, oesophageal disease, hernias, gastritis, ulcers, malabsorption, Crohn’s disease, ulcerative colitis, diverticulitis, Irritable Bowel
Syndrome (IBS), Hemorrhoids, long standing constipation/diarrhea, ongoing abdominal pain, ascites (fluid in the abdomen), any
autoimmune conditions, and any congenital conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

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8.8 Brain and nerve conditions Yes No

Example: stroke, epilepsy, seizures, multiple sclerosis, motor neuron disease, myasthenia gravis, migraine, Parkinson’s disease,
paraplegia, hemiplegia, quadriplegia, spinal cord injury, hydrocephalus, brain shunt (VP shunt used to drain fluid from the brain), intellectual
disability, CVA, bleeding on the brain, any autoimmune conditions, any congenital conditions and down's syndrome.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.9 Breathing and respiratory conditions Yes No

Example: asthma, chronic obstructive pulmonary disease, bronchiectasis, tuberculosis, bronchitis or emphysema, cystic
fibrosis, sarcoidosis, pneumonia, interstitial lung disease/chronic cough > 3months, any autoimmune conditions, and any congenital
conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.10 Musculoskeletal (back, bone and muscle pain) Yes No

Example: arthritis (any form), ongoing/intermittent joint or muscular pain, ankylosing spondylitis, degenerative disc disease, scoliosis,
kyphosis, spinal stenosis, gout, injury, physical disability, prosthesis, amputation, any autoimmune conditions, any congenital conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.11 Kidney or urinary conditions including current or past dialysis Yes No

Example: kidney failure, kidney stones, recurrent urinary infections, glomerulonephritis, nephrotic syndrome, polycystic kidney disease,
urinary incontinence, neurogenic bladder (loss of bladder control or inability to empty the bladder), bladder infections, other bladder or
kidney problems, any autoimmune conditions, and any congenital conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.12 Blood conditions Yes No

Example: deep vein thrombosis, anaemia, polycythaemia vera, blood clotting disorders/diseases, leukaemia, lymphoma, pulmonary
embolus, haemophilia, haemochromatosis and other bleeding disorders, any autoimmune conditions, any congenital conditions, varicose
veins.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

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8.13 Eye conditions Yes No
Example: cataract, keratoconus, corneal ulcer, uveitis, glaucoma, squint, ptosis, retinopathy, macular degeneration, cornea transplant, eye
surgery, blurred vision, eye infections, blindness (partial or full), retinal detachment, any autoimmune conditions, and any congenital
conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.14 Ear, nose and throat (ENT) and dentistry conditions Yes No

Example: otitis media (middle ear infection), otitis externa,(ear canal infection) hearing problems, hearing aid, cochlear implant,
tonsillitis, adenoiditis, vertigo, deafness, sinus problem, nasal surgery, dental treatment or dental surgery, any autoimmune conditions, and
any congenital conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.15 Male urogenital conditions Yes No

Example: prostate disorders, urogenital defects, varicocele, undescended testes, phimosis, urinary incontinence, retention, infertility, any
autoimmune conditions, and any congenital conditions.

Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.16 Are any of your dependants expecting surgery or planning hospitalisation or treatment in the next 12 Yes No
months or have they been admitted to hospital in the last 12 months?
Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

8.17 Have any of your dependants received or not yet received medical advice or treatment for symptoms, not Yes No
yet diagnosed by a medical professional, in the last 12 months before this application?
Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

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8.18 Have any of your dependants been diagnosed with or received treatment for, any condition not Yes No
mentioned in the questions above, in the last 12 months before this application?
Patient name Symptoms/Medical Date first Date of last Medication used for Date of last
diagnosis diagnosed/symptoms symptoms, this condition and treatment taken
consultations and/or dosage
hospitalisation

HIV and AIDS

If you or any one of your dependants are HIV-positive, its crucial to call us on 0800 226 5633 within seven working days from the date we
activate your Bankmed membership. We treat this information with the utmost confidentiality. Registering on the HIVCare Programme is
strongly recommended if you or any of your dependants are HIV-positive. Bankmed may impose waiting periods in certain situations, meaning
there’s a specific timeframe before Bankmed starts covering expenses related to general or specific medical conditions. Consequently, a 12-
month condition-specific waiting period or a three-month general waiting period may be applicable to this condition or any related condition.
Failure to inform us about you or your dependant's HIV status within seven days of activating your membership could lead to your membership
being suspended or cancelled.

9. Bankmed Privacy statement

When you engage with Bankmed Medical Scheme, you are entrusting us with your personal information. We are committed to protecting your
right to privacy and keeping your information safe. Our Privacy Statement tells you how we collect, use and share your personal information,
including personal information about your spouse, employees, dependants, and beneficiaries, where applicable. To view and read our Privacy
Statement, please follow this link:
https://www.bankmed.co.za/wcm/medical-schemes/bankmed/assets/bankmed-privacy-statement.pdf
D D M M Y Y Y Y
Date
Signature of main applicant

Please do not sign an incomplete application form

10. Bankmed terms and conditions

10.1. Rules for membership
10.1.1. Who "we" are
Bankmed (referred to as ‘the Scheme’), registration number 1279, is a non-profit organisation, registered with the Council for
Medical Schemes. Discovery Health (Pty) Ltd (referred to as ‘the administrator’) is a separate company and an authorised financial
services provider (registration number 1997/013480/07) which takes care of the administration of your membership for the
Scheme. Balance (referred to as ‘Balance’) is the health management and wellness programme developed specifically for
Bankmed and its members. Discovery Vitality (referred to as ‘Vitality’) is a separate company (registration number 1999/07736/07)
which carries out business as a Wellness Programme and is appointed by Bankmed to administer Balance.

10.1.2. Rules for membership

The Bankmed Rules records your rights and responsibilities pertaining to your membership of Bankmed. They may change from
time to time.

You may ask us for a copy at any time or you may access them on the website www.bankmed.co.za. When you sign this
application, you confirm that you have read and understood the rules and you agree that you and, those for whom you apply, will
be bound by them.

Where applicable, you also acknowledge and confirm that the financial adviser whom you or your employer appointed, may
communicate with us regarding this application and your membership with Bankmed. You give permission for us to share your
medical information and other relevant Personal Information about you and your dependant/s with your chosen financial adviser.
The information will be shared so that they may contact us if necessary while we process your membership application.

Please speak to your financial adviser or one of our consultants should there be anything you do not understand.

10.1.3. Who you may apply for

You may apply to join Bankmed on your own or together with your dependants i.e. your spouse, your partner and people who are
financially dependent on you, as defined in the Bankmed Scheme Rules. For anyone to be treated as financially dependent for this
application, you must be responsible for providing financially for that dependant. We might ask you to provide us with proof of
financial responsibility. You will be referred to as the Principal Member or Main Member in our future communications to you.

10.1.4. Acting for others

By signing this document, you confirm that:
You have the right to apply for membership and to act for those for whom you are applying in any matter relating to this
application.
You have obtained consent from your spouse and any dependant/s aged 18 years or older to act on their behalf in any matters
pertaining to this application.

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 If you are signing on behalf of a minor (person younger than 18 years) that you are a competent person and authorised to sign
on their behalf

10.1.5. Providing and obtaining information

You must provide true, correct and complete information
To consider your application for membership, Bankmed must learn more about you and those for whom you apply. This information
must be true, correct and complete. This includes the details you provide in this application form and in future dealings with us. It
is important that you inform us of any medical condition, symptom or illness relating to you or those for whom you are applying,
even if you do not consider it to be relevant to your application. We may ask for more information about those for whom you are
applying if they are 18 years of age and older.

Your legal address

We will send documents to you at the address you selected as the communication channel at which you prefer to be contacted. If
it is necessary to send you any legal notices or summonses, our legal team will serve these at the physical address you have
provided, or at any other address you have supplied. It is your responsibility to ensure we have the correct address for you.

Bankmed and Discovery Health (Pty) Ltd may record telephone calls
We may record telephone conversations with you and with those for whom you are applying. The recordings and all information we
obtain therein will be processed and retained as required by law.

We may obtain information about you from other relevant sources

To consider your application for membership, conduct underwriting or risk assessments, consider a claim for medical expenses,
profile and analyse risk or to investigate fraud, waste and/or abuse (including by medical practitioners, contracted service
providers), you agree that we may obtain information about you and those for whom you are applying from other relevant sources.
These include any entity that is part of Bankmed, medical practitioners, financial advisers, credit bureaus or industry regulatory
bodies. We may (at any time and on an ongoing basis) verify with the parties mentioned in this section that the information you
provide on this application and in respect of any matter pertaining to or that arises during your membership of Bankmed, is true,
correct, and complete. You give your permission that we may obtain any information that is relevant to your application and
membership from your employer.

Inform us immediately if your information changes

You, your employer, or your financial adviser must inform us in writing, should any of the information you have provided in your
application for membership change between the day you sign this document and the day on which your membership commences.
This includes information regarding your health and the health of those for whom you apply. We require advance notice of any
administrative changes such as cancellation of membership, as we cannot accept backdated changes.

When Bankmed may suspend or terminate your membership/s

Bankmed may suspend or terminate any memberships immediately, should the member or dependant/s on the membership be
found guilty of abuse of privilege of the Scheme. It is very important for the member and dependant/s to provide true, correct and
complete information on the application form and in their dealings with the Scheme.

10.1.6. Becoming a member

Bankmed might not pay for certain expenses immediately after you become a member.
Bankmed might have waiting periods that apply in certain circumstances. This means there may be a set time period before
Bankmed begins paying for any general or specific medical conditions. Please speak to one of our consultants to find out if waiting
periods apply to your membership and the memberships of those for whom you are applying.

Resign from current medical schemes when accepted

It is illegal to be a member of more than one medical scheme at the same time. You and those for whom you are applying must
resign from your current medical schemes when you receive notice from Bankmed by letter, e-mail, WhatsApp or SMS confirming
that you and those for whom you have applied have been accepted.

You must ensure contributions are paid on time

As the main Bankmed member, you are responsible for ensuring that your contributions and the contributions of those for whom
you are applying, are paid on time every month to avoid suspension of benefits. If you pay your own contribution, you will be able to
identify the debit order for your monthly contributions on your bank statement by the reference “BANKMEDCON.” The Scheme has
the right to amend monthly contributions and benefits from time to time and suspend/terminate membership if the contributions are
in arrears.

10.1.7. Repaying money owed to the Scheme

Bankmed has the right at any time to collect from you any amount that you owe to the Scheme. We will notify you should there be
any such amount owed to the Scheme.

You must repay any medical savings owing should you leave Bankmed
Once you become a member, depending on the Plan you choose, you may have money available in advance to use for medical
expenses during the year. This money is made available in an account called the ‘Medical Savings Account’. Should you leave
Bankmed before the year is up, you must repay the portion of your medical savings you have utilised should it amount to more
than you have paid back to Bankmed over the year. Debit orders for collection of money owing to the Scheme will reflect on your
bank statement as "BANKMEDCLA".

Please note that this form expires on 31/03/2025. Up to date forms are available on www.bankmed.co.za. BANAAD001

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11. Third Party Bank details
Please attach the relevant proof of bank account if you providing a third party bank account for claims refund.
THIRD PARTY ACCOUNT (e.g. spouse, aunt, uncle, friend, father, son)
Proof of the account (bank statement or bank letter not older than three months)
A copy of the third party’s (account holder) ID, Passport or Driver’s Licence
A copy of the Principal Members ID, Passport or Driver’s Licence
JOINT ACCOUNT
Proof of account (bank statement or bank letter not older than three months)
A copy of the ID, Passport or Driver’s Licence of each of the joint
COMPANY ACCOUNT
Proof of account (bank statement or bank letter not older than three months)
A copy of the ID, Passport or Driver’s Licence of the signatories who have authority to sign on behalf of the company
A letter of authority stating that the account can be used including the details of the signatory and stating the membership details for which
the bank account will be used. The letter must be dated, signed by an authorized person on behalf of the company and it must contain the
membership or policy number(s)
A copy of the company’s certificate of registration
A copy of the Principal Members ID, Passport or Driver’s Licence
TRUST ACCOUNT
Proof of account (bank statement or bank letter not older than three months)
A copy of the ID, Passport or Driver’s Licence of each of the trustees of the account
A copy of the Trust’s certificate of registration
A copy of the Trust resolution. The resolution must be dated, signed by an authorized person on behalf of the Trust and it must contain the
membership or policy number(s)
A copy of the Principal Members ID, Passport or Driver’s Licence

If you are completing the request on behalf of the Principal Member, please include proof that you have obtained the necessary authority
(example, Letter of Authority or Letter of Executorship).

Bankmed Medical Scheme is a registered medical scheme and regulated by the Council for Medical Schemes (CMS). The CMS contact details are as follows:
E-mail: complaints@medicalschemes.co.za | Customer Care Centre: 0861 123 267 | Website: www.medicalschemes.co.za | Physical address: Block A Eco Glades 2 Office Park, 420 Witch – Hazel BANAAD001
Avenue, Eco Park Estate, Centurion, 0157

Bankmed Medical Scheme. Registration number 1279. Page 12 of 12

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