Fedhealth Savvy with Bibi "*" indicates required fields Fedhealth Savvy*Savvy Hospital OnlySavvy SavingsInception Date for membership required* DD slash MM slash YYYY The day must be 01full_name* Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last gender_marital status_language Gender Marital Status Language ID_DOB_Country of birth ID/Passport No. Date of Birth Country of Origin Email Income Tax NumberCell Phone Number*Other NumberFull Physical Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Fedhealth Broker Details: OneNet – 59070* I agree1. OneNet is an accredited Fedhealth Financial Adviser and licensed by the Financial Services Board (FSB) in terms of the Financial Advisory and Intermediary Services Act 37 of 2002. 2. I acknowledge that I have appointed OneNet as my financial adviser and that I am entitled to cancel these services at any time. 3. I confirm that I was provided with the personal details, postal address and telephone number of OneNet. 4. I acknowledge that a monthly commission of 3% of the total monthly contribution up to a maximum, as legislated from time to time, will be paid to OneNet in terms of the Medical Schemes Act 131 of 1998 (or as amended). 5. I confirm that there has been no material misrepresentation of any fact by me. 6. I am familiar with the information requested in the application form and all the relevant information was provided. 7. I am familiar with the information relating to the Protection of Personal Information Act (POPIA) as displayed on www.fedhealth.co.za and; 7.1. I, give consent for the Financial Advisor to have access to my data relating to: 1. Personal Information 2. Benefits 3. Financial Information 4. Medical Information 5. Fund Documents 8. The advice and assistance given to me was impartial and in my best interest. 9. I have personally signed the application form. Today's Date* MM slash DD slash YYYY DependantsNoYesName Name Surname ID Number Relationship to You Name Name Surname ID Number Relationship to You Name Name Surname ID Number Relationship to You Is your employer responsible for payment of your subscription?NoYesCompany Details Company Name Organisation Number 1. Have you, or any of your dependents sought advice, been diagnosed or treated with any condition within the past 12 months?NoYesPlease advise?2. Do you, or any or your dependents take chronic medication, or are you expecting to take medication on an ongoing basis?NoYesPlease advise?3. Have you, or any of your dependents been admitted to hospital or undergone any procedure (other than routine medical or dental treatment) in the last 12 months?NoYesPlease advise?4. Are you, or any of your dependents planning or reasonably expecting to be hospitalised or to have a procedure or treatment in the next 12 months, including pregnancy?NoYesPlease advise?5. Are there any other conditions or symptoms not mentioned above for which medical advice, diagnosis, care or teatment has been recommended or received, or could potentially result in a medical claim in the next 12 months that you would like to disclose?NoYesPlease advise?1. Has this application been necessitated by a change in employment which resulted in the cancellation of your membership of a previous medical scheme? (Not applicable to pensioners who belong to closed schemes)NoYes2. Please provide details of ALL the medical schemes where you and your dependants are currently, or have previously been enrolled. NB: The date joined and the date ended are important to place you in the correct enrolment category. Name of Medical Scheme Membership Number Date Joined Date Ended Name of Medical Scheme Membership Number Date Joined Date Ended Bank NameAccount TypeCurrent / Cheque AccountSavings AccountName of Account HolderAccount Number*Today's Date* MM slash DD slash YYYY Consent* I agree and accept the declaration below: 1. The Fedhealth Medical Scheme Rules will apply to this membership and OneNet is the Broker. 2. The Fedhealth membership is conditional upon the receipt of your monthly contributions. If Fedhealth do not receive the monthly contributions, they may suspend and terminate your membership, and the claims will be reversed up to the last monthly contribution received. These costs will then be for your account. 3. It is your responsibility to ensure that you have declared all information relevant to this membership for both you and your dependents. If Fedhealth become aware of any non-disclosures for you or your dependents, then the membership maybe cancelled, and you will forfeit the contributions already paid. 4. Fedhealth has network partners, and you are encouraged to use the Fedhealth network. If you do not use the network partners, you may be liable for a co-payment for non-use and the claims may be reimbursed at a lower rate. 5. You acknowledge that this is a personal statement and is complete, true and correct, and that you have not concealed, withheld or misstated any material facts. 6. You hereby authorize any healthcare provider or any person in possession of this information on you or your dependents health status or any other information required in terms of this application and membership, to make such information available to the scheme or its administrator, including the managed care organization. You confirm that you have your dependents consent to grant this authorisation and you release the scheme, it’s officers, trustee or any other person granted the authority to receive this information from all liability that may arise from this disclosure.Signature*
