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 - Map to ICD10 Code above)
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
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: