Z583 Form PDF Details

In navigating the complexities of planning for healthcare post-retirement or after a significant life event such as the death of a family member, individuals find the Z583 form an essential document. This form, intricately linked with the National Treasury Government Employees Pension Fund (GEPF) in South Africa, serves multiple crucial functions. Firstly, it acts as a conduit for members seeking to ensure continuous medical assistance or to notify about changes in their medical scheme particulars. The comprehensive nature of the Z583 form encompasses detailed sections, ranging from compulsory attachments like ID documents and membership certificates to personal and dependent particulars, showcasing its role in facilitating a seamless transition for medical scheme membership under varying circumstances. Moreover, the inclusion of options for continued State-subsidized membership or a once-off gratuity payment upon retirement or medical discharge highlights the form’s adaptability to individual needs. The necessity for all pages to be completed and initialed underscores the importance of thorough documentation in securing post-retirement medical benefits, making the Z583 form a cornerstone in the process of safeguarding one’s health care provisions.

QuestionAnswer
Form NameZ583 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesz583 form, gems z583, z583 application form, z583 medical scheme membership

Form Preview Example

PLEASE RETURN ALL PAGES, EVEN WHEN PAGES ARE NOT COMPLETED

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N ATI ON AL TREASURY

Gov e r n m e n t Em ploy e e s

Pe n sion Fu n d ( GEPF)

M ED I CAL SCH EM E

M EM BERSH I P – Z5 8 3

Pr iv at e Bag x 63

34 Ham ilt on St r eet

Pr et or ia

Ar cadia

Pr et or ia

SOUTH AFRI CA

 

 

0001

 

 

GEPF USE ONLY - GEPF STAMPS

 

BAR CODE

 

 

Tel No

: ( + 27) ( 0) 12 319 1911

Fax No

: ( + 27) ( 0) 12 326 2507

Call Cent r e

: ( + 27) ( 0) 12 319 1000

E- m ail

: enquir ies@gepf . co. za

WebSit e

: w w w . gepf . co. za

 

 

P A R T I C U L A R S O F M E D I C A L S C H E M E M E M B E R S H I P

T h i s f o r m e n a b l e s t h e G E PF t o s u c c e s s f u l l y p r o c e s s t h e a p p l i c a t i o n f o r c o n t i n u e d M e d i c a l a s s i s t a n c e o r t o

i n d i c a t e a c h a n g e i n M e d i c a l S c h e m e Pa r t i c u l a r s .

C O M P U L S O R Y A T T A C H M E N T S : S e e s e c t i o n B .

A)TYPE OF APPLI CATI ON - Please select only one opt ion

1 . A p p l i c a t i o n f o r c o n t i n u e d M e d i c a l A s s i s t a n c e a f t e r R e t i r e m e n t / D e a t h i n S e r v i c e ( R e s o l u t i o n 3 o f 1 9 9 9 a n d R e s o l u t i o n 1 o f 2 0 0 6 ) ( C o m p u l s o r y i t e m s : B , D , E , F , G , H , I , J a n d K . C i n c a s e o f d e a t h )

2 . C o n t i n u e d M e m b e r s h i p o f M e d i c a l S c h e m e - C h a n g e o f M e d i c a l S c h e m e Pa r t i c u l a r s

( C o m p u l s o r y i t e m s : B , D , E , F , G , H a n d K )

3 . A p p l i c a t i o n o f W i d o w / W i d o w e r f o r c o n t i n u e d M e m b e r s h i p o f M e d i c a l S c h e m e ( C o m p u l s o r y i t e m s : B , C , D , E , F , G a n d K )

B) COM PU LSORY ATTACH M EN TS

All cop ie s of I D d ocu m e n t s sh ou ld b e cle a r , a n d sh ou ld n ot b e old e r t h a n 6 m on t h s.

1 . C e r t i f i e d c o p y o f I D o f t h e m a i n m e m b e r o f t h e M e d i c a l s c h e m e .

2 . Pr o o f o f a l l t h e d e p e n d a n t s r e g i s t e r e d o n y o u r m e d i c a l s c h e m e . C e r t i f i e d c o p y o f I D a n d o r b i r t h c e r t i f i c a t e .

3 . M e m b e r s h i p C e r t i f i c a t e f r o m y o u r m e d i c a l s c h e m e .

4 . M e m b e r D e a t h C e r t i f i c a t e ( i f a p p l i c a b l e )

5 . Pl e a s e i n c l u d e p r e v i o u s m e d i c a l s c h e m e c e r t i f i c a t e ( s ) .

On ly a p p lica b le t o Ty p e 2 Ap p lica t ion s:

C o p y o f l a s t S a l a r y

A d v i c e

C o m p l e t e d Z 8 9 4 - B a n k p a r t i c u l a r s

S e r v i c e C e r t i f i c a t e

C) PERSON AL PARTI CU LARS OF D ECEASED M EM BER

Pension Num ber

Sur nam e

Fir st Nam e

Middle Nam e

Maiden Nam e

Tit le

Dat e of Deat h

I nit

D. O. B

Mar it al St at us

I D No

Mar r ied

 

Un m ar r ied

 

 

 

Widow / er

Div or ced

Life Par t ner

D ) PERSON AL PARTI CU LARS OF APPLI CAN T

Pension Num ber

Sur nam e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fir st Nam e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle Nam e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden Nam e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tit le

 

 

 

I nit

 

 

 

D. O. B

 

 

 

 

 

 

 

 

 

 

 

I D No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I ncom e Tax No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mar it al St at us

 

 

Mar r ied

 

 

 

Unm ar r ied

 

 

Widow / er

 

 

Divor ced

 

 

Life Par t ner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E) CON TACT PARTI CU LARS OF APPLI CAN T

Post al Addr ess

Post al Code

Tel

No

E- Mail

Resident ial Addr ess

Post al Code

Cell No

ALL PAGES OF TH I S FORM M U ST BE COM PLETED I N ORD ER FOR TH I S FORM TO BE V ALI D AN D TH E M EM BER OR

PEN SI ON ER AN D COM M I SSI ON ER OF OATH S M U ST I N I TI AL TH I S PAGE.

Mem ber / Pensioner init ial

Com m issioner of Oat hs init ial

Z583 - MEDICAL SCHEME MEMBERSHIP

November 2007 Revision

PLEASE RETURN ALL PAGES, EVEN WHEN PAGES ARE NOT COMPLETED

Page-2 of 3

Pension Num ber

F)PARTI CU LARS OF D EPEN D AN TS - For any dependant r egist er ed on y our m edical schem e

Sur nam e

Fir st Nam e

I D No / Passpor t num ber

Ty pe *

1 .

2 .

3 .

4 .

5 .

6 .

7 .

8 .

* 1 - Spouse 2 - Child 3 - Disable 4 - St udent 5 - Life Par t ner 7 - Mot her 8 - Fat her 9 - Gr andchild A- Sist er B- Br ot her

G) PARTI CU LARS OF M ED I CAL SCH EM E

The Medical Schem e det ails r efer t o t he cur r ent and n ew m edical schem e

Medical Schem e Nam e

Medical Schem e Num ber

Would y ou lik e t o cont inue y our m em ber ship? Dat e of Benefit

Yes

No

Mem ber ship Com m encem ent Dat e

H ) PARTI CU LARS OF PREV I OU S M ED I CAL SCH EM E

Dat e on w hich m em ber ship w as t er m inat ed

Medical Schem e Nam e

Medical Schem e Num ber

I ) CH OI CE FOR M ED I CAL BEN EFI T UPON RETI REM EN T / D EATH

A s i n g l e c h o i c e b e t w e e n O p t i o n A o r O p t i o n B i s c o m p u l s o r y - Pl e a s e i n d i c a t e c l e a r l y

1 . OPTI ON A - Con t in u e d St a t e Su bsidise d M e m be r sh ip

Su b j e ct t o 1 2 m on t h s con t in u e d m e m be r sh ip of a r e g ist e r e d m e dica l f u n d on t h e la st da y of se r v ice a n d pr e v iou s gov e r n m e n t se r v ice e x ce e din g:

-

15 Year s in r espect of r et ir em ent

-

10 y ear s in r espect of m edical dischar ge

Em ploy er Nam e

St ar t Dat e

End Dat e

Em ploy er Nam e

St ar t Dat e

End Dat e

Em ploy er Nam e

St ar t Dat e

Em ploy er Nam e

End Dat e

St ar t Dat e

End Dat e

OR

2 . OPTI ON B - Gr a t u it y Pa y m e n t ( On ce - off ca sh a m ou n t )

Su b j e ct t o 1 2 m on t h s con t in u e d m e m be r sh ip of a r e g ist e r e d m e dica l f u n d on t h e la st da y of se r v ice on ly if le ss t h a n :

-

15 Year s in r espect of r et ir em ent

-

10 y ear s in r espect of m edical dischar ge

ALL PAGES OF TH I S FORM M U ST BE COM PLETED I N ORD ER FOR TH I S FORM TO BE V ALI D AN D TH E M EM BER OR

PEN SI ON ER AN D COM M I SSI ON ER OF OATH S M U ST I N I TI AL TH I S PAGE.

Mem ber / Pensioner init ial

Com m issioner of Oat hs init ial

Z583 - MEDICAL SCHEME MEMBERSHIP

November 2007 Revision

 

 

 

 

 

 

 

 

 

PLEASE RETURN ALL PAGES, EVEN WHEN PAGES ARE NOT COMPLETED

 

 

 

 

 

 

 

Page-3 of 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pension Num ber

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J) TO BE COM PLETED BY TH E LAST EM PLOYER D EPARTM EN T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

St at e Cont r ibut ion t o m em ber m edical aid on last day of ser v ice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last day of em ploy m ent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for r et ir em ent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ser v ice r ecor d in gov er nm ent depar t m ent s or r elat ed inst it ut ions. All per iods of ser v ice m ust be fur nished:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fr om

 

To

Depar t m ent or I nst it ut ion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I ce r t ify t h a t a ll pa r t icu la r s in t h is for m a r e t r u e a n d cor r e ct .

Officia l D a t e St a m p of Em ploy e r

Sig n a t u r e 1

 

Desig n at ion

Sur nam e of Em ployer

Repr esent at iv e

Tel No

Fax No

E- Mail addr ess

K) CERTI FI CATI ON PARTI CU LARS

Ideclar e t hat all t he par t icular s fur nished on t his for m is t r ue and cor r ect .

Signat ur e or Thum bpr int of Mem ber

Dat e

Com m issioner St am p

Declar ed and signed befor e m e

Com m issioner of Oat hs

Dat e

Z583 - MEDICAL SCHEME MEMBERSHIP

November 2007 Revision

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Filling in section 1 in z583 form download

2. The third step is usually to submit the following blank fields: Tit le, Dat e of Deat h, I nit, DOB, I D No, Mar it al St at us, Married, Unm arried, Widow er, Divorced, Life Part ner, D PERSON AL PARTI CULARS OF APPLI, Pension Num ber, Surnam e, and Fir st Nam e.

Completing segment 2 in z583 form download

3. Completing Tel No E Mail, Cell No, ALL PAGES OF TH I S FORM M UST BE, PEN SI ON ER AN D COM M I SSI ON, Mem ber Pensioner init ial, Com m issioner of Oat hs init ial, Z MEDICAL SCHEME MEMBERSHIP, and November Revision is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

z583 form download writing process detailed (portion 3)

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4. Your next paragraph needs your input in the following places: PLEASE RETURN ALL PAGES EVEN WHEN, Page of, Pension Num ber, F PARTI CULARS OF D EPEN D AN TS, Surnam e, First Nam e, I D No Passport num ber, Type, Spouse Child Disable St udent, G PARTI CULARS OF M ED I CAL SCH, and The Medical Schem e det ails refer. Ensure you fill in all needed information to move onward.

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5. The last step to finish this document is integral. Make certain you fill out the displayed blanks, and this includes Medical Schem e Nam e, Medical Schem e Num ber, Would you like t o cont inue your, Yes, Dat e of Benefit, Mem ber ship Com m encem ent Dat e, H PARTI CULARS OF PREV I OUS M ED, Dat e on which m em bership was t, Medical Schem e Nam e, Medical Schem e Num ber, I CH OI CE FOR M ED I CAL BEN EFI, A s i n g l e c h o i c e b e t w, OPTI ON A Con t in u e d St a t, Su bj e ct t o m on t h s con t, and Year s in r espect of ret ir em, prior to using the pdf. If not, it could contribute to an incomplete and possibly incorrect document!

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