I authorise Sizwe Hosmed to draw from my bank account (wherever it may be), the contribution and members portion of claims due in terms of the Rules of Sizwe Hosmed, without prejudice to the rights of Sizwe Hosmed. I further authorise Sizwe Hosmed to increase the amounts due, in terms of the rules, and authorise my bank to effect payment of such increased amounts upon receipt of a written notice from Sizwe Hosmed stating the increased amount and the date from which it is payable. This authorisation is to remain in effect until I cancel it by giving written notice to Sizwe Hosmed. I agree that I am not entitled to recover any amount drawn from my account by means of this debit order and that should my bank repay such amount to me, I will refund
it immediately to Sizwe Hosmed. I undertake to notify Sizwe Hosmed immediately of any change in respect of my details. I acknowledge that Sizwe Hosmed may not cede or assign any of their right to any third party without my prior consent and that I may not delegate any of my obligations in terms of the contract to any third party without prior written consent of the authorised party. Sizwe Hosmed is hereby authorised to debit by bank account with my portion of accounts paid on my behalf by Sizwe Hosmed.
I hereby instruct and authorise you to pay any claim reimbursement which may accrue to me, to the credit of my account with the abovementioned bank or any other bank or branch to which I may transfer my account.
I understand that remittance advice/payment advices will be supplied to me in the normal way and that they will indicate the date on which funds will be available in my account.
I acknowledge that the party hereby authorised to effect a credit against my account may not cede or assign any of its rights to any third party without my prior written consent and that I may not dele- gate any of my obligations in terms of this contract/authority to any third party without written consent of the authorised party.
This authority may be cancelled by me giving you thirty day’s notice in writing.
I, blanks hereby declare that:
(a) The information furnished herein is to the best of my knowledge and ability completely true. No relevant information has been omitted.
(b) If, after my admission to Sizwe Hosmed, it is found that any statement or information furnished by me was knowingly and willfully inadequate or untrue, I agree to refund in full to Sizwe Hosmed all payments which Sizwe Hosmed may have made on my behalf and to relinquish any claim to any benefits on the part of Sizwe Hosmed, should Sizwe Hosmed request me to do so.
(c) Should there be any deterioration or change in my state of health or in that of any of my dependants before the date or event to be set by Sizwe Hosmed for commencement of membership or the date of acceptance of this application by Sizwe Hosmed or the date of receipt of the first contribution, (whichever date is the latest) or thereafter, Sizwe Hosmed will be entitled to reconsider the application and purport new terms of admission or declare the membership null and void, depending on the relevant circumstances. Any sum of money paid to Sizwe Hosmed in terms of this membership, before Sizwe Hosmed is informed of the said change, shall be forfeited by me and any benefits paid by Sizwe Hosmed on my behalf shall immediately be refunded by me to Sizwe Hosmed, on the request of Sizwe Hosmed.
(d) I accept that I and/or my dependants may be subjected to a general waiting period of three months. For any pre-existing conditions within the last twelve months, a waiting period of twelve months may be applied.
(e) I accept that should any sum of money due to Sizwe Hosmed not be timeously paid by me for any reason whatsoever, I shall be liable for all costs incurred by Sizwe Hosmed in recovering such a claim, including tracing charges and all fees and costs charged to Sizwe Hosmed by its attorneys, including collection commission or fees.
(f) I undertake to notify Sizwe Hosmed within (30) thirty days of any change in my marital status and or dependant status that occurred since the commencement of my membership with Sizwe Hosmed.
(g) Should I decide to resign my membership from Sizwe Hosmed voluntarily, I undertake to give one month’s written notice.
(h) I will call Sizwe Hosmed Customer Services on 0860 00 00 48 for any pre-authorised treatment inquiries.
(i) I herewith authorise my healthcare provider to disclose information to Sizwe Hosmed and its contracted third parties, provided such information is treated as confidential at all times.
(j) Should I be enrolled as a member of Sizwe Hosmed, I will subject myself to the Rules of Sizwe Hosmed.
(k) I irrevocably grant my permission to any physician, person or party who may be in possession of, or obtain information concerning my health, or that of my dependants, to divulge such information to Sizwe Hosmed, also after my death.
(l) I confirm that I am employed by my Employer in a full time capacity and I undertake to notify Sizwe Hosmed of any change in my salary structure.
(m) I undertake to pay any other amounts due to Sizwe Hosmed, on default.
(n) I hereby authorise my Employer to deduct my contribution to Sizwe Hosmed from any salary or any other sum of money due to Sizwe Hosmed by me.
(o) Where applicable: Member Savings Account allocations will be pro-rated depending on when joining the option.
(p) I must register my chronic medication with Sizwe Hosmed.
(q) I agree to access www.sizwehosmed.co.za to access full conditions and undertakings of the Scheme as a member of Sizwe Hosmed Medical Scheme.