MediCheck Member Medical Aid Complaint Assessment (Doctor Submission)

MediCheck Member Medical Aid Complaint Assessment (Doctor Submission)

Doctor-submitted form for MediCheck member complaints. Please ensure you have obtained patient consent before completing and sending this form directly to MediCheck.
Patient Full Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Aid Scheme
Medical Aid Number
Patient Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address
example@example.com
Patient Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Doctor Full Name

First NameLast Name
Doctor Practice Number
Doctor Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor Email Address
example@example.com
Is this a CDL or PMB Condition
Chronic Condition ICD10 Code
Prescribed Minimum Benefit (PMB Code)
- ICD-10 Codes A00 to C97
- ICD-10 Codes D00 to G99
- ICD-10 Codes H00 to L99
- ICD-10 Codes M00 to N99
- ICD-10 Codes O00 to Q99
- ICD-10 Codes R00 to S99
- ICD-10 Codes T00 to Z99 (excluding X)
- ICD-10 Codes X00 to X99 external causes (search by code)
- Medicine (active ingredient)
  Search by generic name, e.g. eculizumab. Source: NDoH Database of Medicine Prices, 1 October 2026.
- Medicine brand name, strength and NAPPI code
  e.g. brand name, strength, dosage form and NAPPI code
- Scheme's response to the medicine
- Claim or Authorisation Reference Number
- Scheme's Stated Reason for Decline/Dispute
- Specific Benefit Option/Plan Name
- Date of Service
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Date of Decline
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Urgency Indicator
- Amount/Cost in Dispute
- Facility/Hospital Name
- Prior Escalation History
- Nature of Complaint
- Supporting Documents (Pathology, Histopathology, MRI,CT, Motivational Letters etc - Maximum File Size 10 Meg)
  
  Cancelof
- Consent Confirmation - Copy of Patient Consent MUST be attached
- Consent Confirmation - Copy of Patient Consent MUST be attached
  
  Cancelof
- By signing below, I confirm that I am the treating doctor and have obtained the patient's consent to complete and submit this form directly to MediCheck on their behalf.
- Doctor's Signature
- Should be Empty: