PMB Form | Discovery

Application for out-of-hospital treatment of a Prescribed Minimum Benefit condition 2025
Discovery Health Medical Scheme, registration number 1125, is a not-for-profit organisation registered with the Council for Medical Schemes, and is the medical scheme that you are a member of. Discovery Health (Pty) Ltd, registration number 1997/013480/07, is a separate company and an authorised financial services provider and is the administrator and managed care organisation for Discovery Health Medical Scheme and takes care of the administration of your membership.

Tel (members): 0860 99 88 77, Tel (health partners): 0860 44 55 66, www.discovery.co.za, PO Box 784262, Sandton, 2146, 1 Discovery Place, Sandton, 2196.

This form is to apply for out-of-hospital treatment of a Prescribed Minimum Benefit condition.
What you do
You need to complete section 1 of this form. Fill in the form in black ink and print clearly, or complete the form digitally. All relevant sections must be signed by the patient. Your healthcare professional must complete section 2.1, 2.2, 2.3, 2.4 and section 3 to apply for treatment for a Prescribed Minimum Benefit. Please include detailed documentation to support your application.
Patients Details
Title
Initials
First Name
Surname
Gender

MaleFemale
Pronoun
Date of birth*

MonthDayYear
Date
Age in years
Age in days
ID or passport number
Country of issue
Membership number
Cell number
Please enter a valid phone number.
Email
example@example.com
Consent for processing my personal information

I give the Scheme and the administrator consent to have access to and process all information (including general, personal, medical or clinical information) that is relevant to this application. I understand that this information will be used for the purposes of applying for and assessing my funding request for Prescribed Minimum Benefits (PMBs I consent to the Scheme and the administrator disclosing, from time to time, information supplied to them (including general, personal, medical or clinical information) to my healthcare provider and to relevant third parties, to administer the Prescribed Minimum Benefits (PMBs) as well as undertake managed care interventions related to the Prescribed Minimum Benefit (PMB) condition. The above consent can be withdrawn at any time by following the process outlined on the website www.discovery.co.za

	Condition	ICD-10 Code	Procedure description	Quanitity required	Procedure codes	Motivation
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Date

DayMonthYear
Date
Signature

Clear
Please only sign if information is true, complete and correct.

(if patient is a minor, main member to sign)
2. Application

(Healthcare professional to complete)
Date

DayMonthYear
Date
2. Healthcare professionals Details (Healthcare Professional to complete)
Practioners First name and Surname
Physiotherapist Email*
example@example.com
Signature of healthcare professional (Please only sign if information is true, complete and correct)

Clear
Date

DayMonthYear
Date
Current Issues

global deconditioningright sided weaknesslower limb weaknessleft sided weaknessupper limb weaknessincreased Tonelymphedemadecreased tonedecreased Range of Motiondyspneapost-surgical painproductive coughpost-surgical lower limb weaknessunproductive coughpost-surgical deconditioningreduced exercise tolerancepost-surgical decreased rangeimpaired airway clearancefunctional limitationsimpaired gas exchangepost-surgical complicationsrespiratory muscle dysfunctionOther
Rehab Prognosis

very poorpoorfairgoodvery goodexcellentof unsure natureOther
Goals for OPD therapy
Treatment Plan

mobility trainingtransfer traininggait Trainingbalance trainingpatient educationassistive device trainingstrength trainingflexibility trainingfunctional trainingstair climbingweight bearing activitiesprogressive ambulation trainingfunctional walking exercisesstatic and dynamic balance exercisesproprioceptive trainingfall prevention strategies and educationweight-shift exercisesresistance trainingfunctional strengtheningcardiovascular exercisesgraded walking programaerobic conditioningcore muscle activation exercisespostural correction techniquespilates-based exercises for control and stabilitycoordination drillsfacilitation techniques such as Proprioceptive neuromuscular Facilitationmotor learning taskssoft tissue mobilization and massageheat therapyactive and passive range of motion exercisesstretching programsjoint mobilization techniquesbreathing exercises including diaphragmatic breathingairway clearance techniquesinspiratory muscle trainingsimulated real-life activities for independenceactivities of Daily Living trainingdual-task training combining physical and cognitive taskshome exercise program developmenteducation on safe mobility and falls preventiontraining caregivers in patient handling techniquescold therapyOther
Baseline mobility level prior to admission

bed bound, fully dependent on all bed mobilityable to roll from side to side in bedable to move around in bedable to change body position in bedable to mobilise from lying to sittingable to maintain body position in sittingable to sit over the edge of bedable to transfer from bed to chairable to transfer from chair to bedable to transfer to wheelchair from bedable to sit to standable to standable to march on the spotable to take a few steps (3-5)able to walk within bedroomable to walk to bathroomable to walk short distances (50m)able to walk short distances (100m)able to walk short distances (200m)able to walk short distances (300m)able to walk 500metresable to walk 800metresable to walk on different surfacesable to walk long distances (1km)able to walk around obstaclesable to walk on outdoor terrainsable to do a step up on a stepable to climb a few stairs (3-5) using hand railingable to climb a few stairs (3-5)able to climb a full flight of stairs using hand railingable to climb a full flight of stairsable to climb stairs one step at a time using hand railingable to climb stairs one step at a timeable to confidently climb stairs with alternating stepsable to climb stairs, even when carrying itemsable to independently move around in wheelchairable to sit independently in wheelchairOther
Mobility device prior to admission

no assistive devicea walking sticka walking framea rollator1 x Elbow Crutch2 x Elbow Crutchesa two-wheel Walkera four-wheel Walkera Knee Scootera wheelchaira nordic walking sticka quadrapoda hoista transfer boardOther
Baseline dependence

independentlywith supervisionwith minimal assistance from 1 personwith moderate assistance from 1 personwith moderate assistance from 2 peoplewith maximal assistance from 1 personwith maximal assistance from 2 peoplefully dependentOther
Assessment: mobility level on admission to sub-acute

bed bound, fully dependent on all bed mobilityable to roll from side to side in bedable to move around in bedable to change body position in bedable to mobilise from lying to sittingable to maintain body position in sittingable to sit over the edge of bedable to transfer from bed to chairable to transfer from chair to bedable to transfer to wheelchair from bedable to sit to standable to standable to march on the spotable to take a few steps (3-5)able to walk within bedroomable to walk to bathroomable to walk short distances (50m)able to walk short distances (100m)able to walk short distances (200m)able to walk short distances (300m)able to walk 500metresable to walk 800metresable to walk on different surfacesable to walk long distances (1km)able to walk around obstaclesable to walk on outdoor terrainsable to do a step up on a stepable to climb a few stairs (3-5) using hand railingable to climb a few stairs (3-5)able to climb a full flight of stairs using hand railingable to climb a full flight of stairsable to climb stairs one step at a time using hand railingable to climb stairs one step at a timeable to confidently climb stairs with alternating stepsable to climb stairs, even when carrying itemsable to independently move around in wheelchairable to sit independently in wheelchairOther
Mobility device on assessment

no assistive devicea walking sticka walking framea rollator1 x Elbow Crutch2 x Elbow Crutchesa two-wheel Walkera four-wheel Walkera Knee Scootera wheelchaira nordic walking sticka quadrapoda hoista transfer boardOther
Assessment dependence

independentlywith supervisionwith minimal assistance from 1 personwith moderate assistance from 1 personwith moderate assistance from 2 peoplewith maximal assistance from 1 personwith maximal assistance from 2 peoplefully dependentOther
Goal mobility level

bed bound, fully dependent on all bed mobilityable to roll from side to side in bedable to move around in bedable to change body position in bedable to mobilise from lying to sittingable to maintain body position in sittingable to sit over the edge of bedable to transfer from bed to chairable to transfer from chair to bedable to transfer to wheelchair from bedable to sit to standable to standable to march on the spotable to take a few steps (3-5)able to walk within bedroomable to walk to bathroomable to walk short distances (50m)able to walk short distances (100m)able to walk short distances (200m)able to walk short distances (300m)able to walk 500metresable to walk 800metresable to walk on different surfacesable to walk long distances (1km)able to walk around obstaclesable to walk on outdoor terrainsable to do a step up on a stepable to climb a few stairs (3-5) using hand railingable to climb a few stairs (3-5)able to climb a full flight of stairs using hand railingable to climb a full flight of stairsable to climb stairs one step at a time using hand railingable to climb stairs one step at a timeable to confidently climb stairs with alternating stepsable to climb stairs, even when carrying itemsable to independently move around in wheelchairable to sit independently in wheelchairOther
Goal Mobility device

no assistive devicea walking sticka walking framea rollator1 x Elbow Crutch2 x Elbow Crutchesa two-wheel Walkera four-wheel Walkera Knee Scootera wheelchaira nordic walking sticka quadrapoda hoista transfer boardOther
Goal dependence

independentlywith supervisionwith minimal assistance from 1 personwith moderate assistance from 1 personwith moderate assistance from 2 peoplewith maximal assistance from 1 personwith maximal assistance from 2 peoplefully dependentOther
Possible complications if no auth given

SwellingJoint stiffnessContracturesRespiratory infectionsSevere disabilityMuscle weaknessImpaired balanceRisk of fallsPainInfection riskMuscle atrophyJoint stiffnessPressure ulcersBlood clotsRespiratory issuesMental health declineFalls riskChronic painReduced independenceDecreased mobilitySpasticityContracturesPressure soresMalnutritionDeep vein thrombosisSeizuresShoulder subluxationNonunionMalunionRespiratory failureChronic hypoxiaDecreased lung capacityAtelectasisPulmonary infectionsReduced exercise toleranceAnxiety or depressionPoor quality of lifeIncreased hospitalizationsPhantom limb painPoor prosthetic fittingGait abnormalitiesSocial isolationAutonomic dysreflexiaOsteoporosisLoss of Functional SkillsPoor Cardiovascular HealthDelayed HealingScarring and AdhesionsPoor CoordinationOther
{title} {firstName8} {surname} is a {ageIn247}-year-old {gender}

{pronoun} was referred to our practice for out-patient physiotherapy to continue with intensive rehabilitation, focusing on optimizing recovery, functional independence, and overall quality of life.

{pronoun} currently present with {currentIssues}

Rehab prognosis: {currentIssues251}

Goals of physiotherapy as an out-patient are as follows:

{typeA}

Treatment plan includes {treatmentPlan}
- Before the patient was admitted to hospital they were {baselineMobility} using {typeA256} {typeA257}.
- On assessment they were {assessmentMobility} using {mobilityDevice} {assessmentDependence}.
- Our main goal is to ensure that the patient is able to {goalMobility} using {goalMobility262} {goalDependence}.
To achieve the desired outcomes and the goals set, the patient requires an approval of their PMB authorisation for out-of-hospital physiotherapy benefit. This authorisation would ensure that we reach the desired therapeutic goals and prevent any further implications or side effects relating to their condition. This rehabilitation will help prevent complications, including {possibleComplications}. By optimising the rehabilitation process, we aim to reduce the likelihood of further medical interventions, readmissions, or long-term impairments, ensuring the patient returns safely to their daily activities with the best possible outcomes.

Tokai Physiotherapy Inc

{practionersFirst}

021 001 8291

team@tokaiphysiotherapy.co.za

www.tokai.physio
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What you do

Patients Details

2. Application