MediCheck Member FREE Assessment Form

MediCheck Member FREE Assessment Terms and Conditions Apply

Complete this form to provide member details, complaint information, required consent, mandate authorisation, member confirmation, and fee structure acceptance for MediCheck dispute resolution This form is secure and POPIA compliant under the POPIA 4 Act of 2013. Minimum turnaround time is 24 to 48 hours. Operating days are Sunday to Friday only.
Member and Contact Details
First Name
Surname
Email Address
example@example.com
Full Address

Street Name 1

Street Name 2
CityProvincePostal Code
Phone Number

Area CodePhone Number
Medical Aid
Medical Aid Plan Option
Medical Aid Number
Authorisation Reference / Claim Number / Case Number
Provider and Complaint Details
Full name of treating doctor, specialist or hospital
Phone Number of Provider

Area CodePhone Number
Type of Complaint
Date of Decline or Incident

DayMonthYear
Medicine involved (if any)
Type part of the medicine name to search. Choose "Not listed" if you cannot find it.
Medicine name and strength as on the box or script
e.g. the name and strength printed on the box, plus the NAPPI code if you have it
What did your Medical Scheme do about the medicine?
Describe what happened - what your scheme declined, the reason given, and the impact on your healthcare
Total Rand value of the disputed amount
Upload Supporting Documents Maximum 10 Megabytes

Cancelof
Additional Notes for MediCheck
Consent and Mandate
Consent for MediCheck to collect and process my personal and medical information for member advocacy and dispute resolution
I acknowledge that my information will be kept strictly confidential, stored securely under POPIA, retained for 5 years, and then securely destroyed
I authorise MediCheck to communicate with the Medical Aid Scheme, treating clinicians, the Council for Medical Schemes, and relevant third parties on my behalf
I confirm the mandate and authorisation statement for MediCheck (Bermar Holdings 2018 Pty Ltd, Reg 2018/466342/07) under the Medical Schemes Act 131 of 1998 and the Protection of Personal Information Act 4 of 2013 (POPIA)
Signature - Consent and Mandate (Protection of Personal Information Act 4 of 2013)
Date of Signature (Mandate and authorisation)

DayMonthYear
Member Confirmation and Fee Acceptance
I confirm that I accept these terms
Date of signature

DayMonthYear
I acknowledge that I have read and understood the MediCheck Fee Structure and accept the Terms thereof
Signature - Acceptance of Fee Structure
Should be Empty:

MediCheck Member FREE Assessment Terms and Conditions Apply

Member and Contact Details

Provider and Complaint Details

Consent and Mandate

Member Confirmation and Fee Acceptance