Bonitas Dependant Registration Form PDF Details

Navigating through healthcare bureaucracy can often seem daunting, but understanding the essentials of forms like the Bonitas Dependant Registration can streamline the process significantly. This document is crucial for members who wish to add dependants to their health insurance coverage, ensuring that spouses, partners, children, or any additional adult dependant receive the benefits they need. The form is meticulously structured, starting with comprehensive membership details that are obligatory for registering dependants. Members are also prompted to update vital information such as contact, banking details, and to declare any changes in marital status or the termination of a dependant's membership, which are critical for maintaining accurate and up-to-date records. Moreover, the form delves into confirmations of address, banking particulars for direct transactions, and medical history, emphasizing the importance of full disclosure to avoid any future complications regarding coverage. Inclusively, the registration process involves submitting supporting documents like ID copies and marriage or birth certificates, further emphasizing the scheme's diligence in safeguarding its members and dependents. Lastly, sections dedicated to previous medical scheme information and employer details underline the necessity of transparency and completeness in these administrative procedures, ultimately designed to foster a seamless integration of new dependants into the Bonitas Medical Fund ecosystem.

QuestionAnswer
Form NameBonitas Dependant Registration Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesbonitas newborn registration form 2021, bonitas forms 2021, bonitas form, bonitas newborn registration

Form Preview Example

Section 1 MEMBERSHIP DETAILS (must be completed)

Title

 

 

 

 

Initials

 

 

 

 

 

 

First name/s

Surname

Membership number

DEPENDANT REGISTRATION

 

P.O. Box 1101, Florida Glen 1708

 

Call Centre

0860 002 108

 

Fax

011 758 7171

 

E-mail

bonitasmemmaintenance@medscheme.co.za

 

 

IMPORTANT

¥ Section 1 must be completed for dependant/s to be registered

¥ If you have any queries, please contact the Call Centre on 0860 002 108

 

¥ Please use block letters

 

¥ Complete blocks from left to right, one letter/number per block

¥ Registration and amendments are subject to the Rules of the Fund

¥ Please notify the Fund, within 30 days, of any change to the membership status of your dependant/s

Please

 

appropriate block

 

 

 

 

 

 

 

 

 

 

 

Change of address / contact details

Complete Sections 1, 2 and 6

 

 

 

 

Change of bank details

Complete Sections 1, 3 and 6

 

 

 

 

 

 

Change of marital status

Complete Sections 1, 4 and 6

 

 

 

 

 

 

 

 

 

 

Termination of dependant membership Complete Sections 1, 5 and 6

Section 2 CONFIRMATION OF ADDRESS / CONTACT DETAILS

Telephone (H)

c

o

d

e

 

 

 

 

 

 

 

Telephone (W)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c

o

d

e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postal address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c

o

d

e

 

 

 

 

 

 

 

 

 

 

 

 

E-mail address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell

Fax

Street address

c o d e

c o d e

Section 3 BANK DETAILS OF PRINCIPAL MEMBER Ð Refund of claim and savings payments / debt order instruction Please provide the following documents:

If Account Holder differs from that of Principal Member, an Affidavit is required.

¥Copy of the account holders ID

¥Copy of the bank statement / cancelled cheque / letter from the bank / bank letterhead confirming the account holderÕs details

¥Account holders signature

Use this account for contribution collections and refunds

Use this account for contribution collections

 

Use this account for claims and savings refunds only

 

 

 

Bank name

Branch name

Bank branch code

Type of account

Cheque

Transmissions

Savings

please

Bank name

Branch name

Bank branch code

Type of account

Cheque

Transmissions

Savings

please

Name of account holder

Bank account number

Name of account holder

Bank account number

Date signed d d m m y

Account holderÕs signature

y y y

Section 4 REGISTRATION OF SPOUSE / PARTNER / NEWBORN / ADDITIONAL ADULT OR CHILD DEPENDANT

An adult dependant is anyone who is 21 years of age or older. Child rates apply to fullÐtime students 21-24 years of age provided the student proof (registration details) is attached to the application for the current academic year. You are able to register adult or child dependants on this form. Provide valid ID numbers and/or passport numbers for all beneficiaries. Acceptance of the dependants will be in accordance with the Rules of the Fund. Please attach copies of ID / passport, marriage certificates, birth certificates, legal adoption or foster care court order documents and previous membership certificates with the terminated date.

1

Adult

 

Surname

(if different from principal member)

First name/s

Relationship to principal member

Child

 

Title

 

 

 

 

Initials

 

 

 

 

 

 

 

 

Gender

M

F

Date of birth

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

Marital status

Single

Married

Divorced

Widowed

Cohabiting

Maiden name (if applicable)

ID / passport number

Tax number (if applicable)

2

Adult

Surname

(if different from principal member)

First name/s

Relationship to principal member

Child

 

Title

 

 

 

 

Initials

 

 

 

 

 

 

 

 

Gender

M

F

Date of birth

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

Marital status

Single

Married

Divorced

Widowed

Cohabiting

Maiden name (if applicable)

ID / passport number

Tax number (if applicable)

3

Adult

Surname

(if different from principal member)

First name/s

Relationship to principal member

Child

 

Title

 

 

 

 

Initials

 

 

 

 

 

 

 

 

Gender

M

F

Date of birth

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

Marital status

Single

Married

Divorced

Widowed

Cohabiting

Maiden name (if applicable)

ID / passport number

Tax number (if applicable)

4

Adult

Surname

(if different from principal member)

First name/s

Relationship to principal member

Child

 

Title

 

 

 

 

Initials

 

 

 

 

 

 

 

 

Gender

M

F

Date of birth

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

Marital status

Single

Married

Divorced

Widowed

Cohabiting

Maiden name (if applicable)

ID / passport number

Tax number (if applicable)

Section 5 MEDICAL DETAILS

Failure to disclose existing medical conditions could limit and / or exclude you from receiving certain benefits, or result in the termination of your membership.

1.Do you or any of your dependants suffer from a chronic illness (e.g. raised cholestrol, heart problems, diabetes, high or low blood pressure, asthma, SLE, depression, anxiety, epilepsy, and / or thyroid disorders)? If yes, provide details.

Yes No

Name of beneficiary

Condition

Name of medication

Are you currently

 

Date of treatment

 

Attending doctor

receiving treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

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m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.Do you or any of your dependants suffer from any gastro-intestinal disorders (e.g. gastro-oesophageal reflux disease, heartburn, stomach or duodenal disorders, CrohnÕs disease, ulcerative coilitis, diverticuilitis and / or a spastic colon)? If yes, provide details.

Yes No

Name of beneficiary

Condition

Name of medication

Are you currently

 

Date of treatment

 

Attending doctor

receiving treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.Do you or any of your dependants suffer from muscle, bone, skin or nerve illnesses or disorders (e.g. back- and neck-related conditions including injury, arthritis, gout, multiple sclerosis, knee or hip problems, osteoporosis, dermatitis etc.)? If yes, provide details.

Yes No

Name of beneficiary

Condition

Name of medication

Are you currently

 

Date of treatment

 

Attending doctor

receiving treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.Do you or any of your dependants suffer from urinary or genital disorders (e.g. kidney stones, prostate, endometriosis, ovarian cysts, menstrual disorders)? If yes, provide details.

Yes No

Name of beneficiary

Condition

Name of medication

Are you currently

 

Date of treatment

 

Attending doctor

receiving treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.Do you or any of your dependants suffer from ear, nose or throat disorders (e.g. glaucoma, cataracts, visual disorders, deafness, rhinitis, orthodontics)? If yes, provide details.

Yes No

Name of beneficiary

Condition

Name of medication

Are you currently

 

Date of treatment

 

Attending doctor

receiving treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 5 MEDICAL DETAILS Ð continued

6.Do you or any of your dependants suffer from any blood disorders, immune deficiency state, HIV / Aids, cancer, etc.? If yes, provide details.

Yes No

Name of beneficiary

Condition

Name of medication

Are you currently

 

Date of treatment

 

Attending doctor

receiving treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.Are you or any of your dependants pregnant? If yes, provide details.

Yes No

Name of beneficiary

 

Expected delivery date

 

Attending doctor

 

 

 

 

 

 

 

 

 

 

 

 

 

d

 

d

m

m

y

y

y

 

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d

 

d

m

m

y

y

y

 

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d

 

d

m

m

y

y

y

 

y

 

 

 

 

 

 

 

 

 

 

 

 

 

8.Have you or any of your dependants had surgery in the past, or are you planning to have a surgical procedure in the next 12 months? If yes, provide details.

Yes No

Name of beneficiary

Condition

Name of medication

Are you currently

 

Date of treatment

 

Attending doctor

receiving treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.Is there any other condition or symptoms not listed above, for which medical advice, diagnosis, care or treatment has been recommended or received, or could potentially result in a medical claim in the next 12 months? If yes, provide details.

Yes No

Name of beneficiary

Condition

Name of medication

Are you currently

 

Date of treatment

 

Attending doctor

receiving treatment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current doctor

Name and surname

Telephone

c o d e

He / she has been your doctor for

y y m m

years

Section 6 PREVIOUS MEDICAL SCHEME INFORMATION

 

 

 

 

Please attach copy of the previous certificate of membership with the terminated date.

 

 

 

 

 

Yes

No

 

Have you as the principal member, or any of your dependants had previous medical aid cover?

If yes, please give full details of you and / or your spouse / partner /

 

 

adult dependantsÕ membership of previous registered medical aid schemes and attach a copy of previous Membership Certificate. Should you need additional space to provide the necessary information, please make a copy of this section and attach it to your application. It is important that you specify exact membership join and termination dates for each medical scheme.

Name of beneficiary

Name of scheme

Membership number

 

 

Date joined

 

 

 

 

Date terminated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d

d

m

m

y

y

y

y

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d

d

m

m

y

y

y

y

d

d

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d

d

m

m

y

y

y

y

d

d

 

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d

d

m

m

y

y

y

y

d

d

 

m

m

y

y

y

y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you changing your medical scheme due a change in your employment? If yes is selected please provide a letter from previous employer confirming termination of employment or letter from new employer or new employment.

Have condition-specific waiting periods, exclusions or late-joiner penalties ever been imposed by a previous medical scheme/s on medical scheme applications by your partner / spouse or any of your dependants?

Yes No

Yes No

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