Mmmmmmmmmmmmmm

First name(s)

Sex

M

F

Identity number

(W)

Cellphone

Fax

Email

The outcome of this application can be communicated to me by email

Yes

No

or fax number

Yes

No

I give permission for my doctor to provide Discovery Health with my diagnosis and other relevant clinical information required to review my application for the

Chronic Illness Benefit. I understand that:

1. funding from the Chronic Illness Benefit is subject to clinical entry criteria and drug utilisation review as determined by Discovery Health

2. the Chronic Illness Benefit provides cover for disease-modifying therapy only, which means that not all medicines for a listed condition are automatically

covered by the Chronic Illness Benefit

3. by registering for the Chronic Illness Benefit, I agree that my condition may be subject to disease management interventions and periodic review and that this

may include access to my medical records. I understand that not doing this may lead to the withdrawal of this benefit

4. medicine approved by the Chronic Illness Benefit will only be effective from when Discovery Health receives an application form that is completed in full

5. the covered Chronic Illness Benefit conditions and clinical entry criteria may change from time to time and I may need to send an updated or new application

form, if the Chronic Illness Benefit department asks for this.

By signing this, I also give my consent that Discovery Health may, from time to time, disclose any information supplied to them – including general or medical

information – to my appointed financial adviser or any other third party. I agree that Discovery Health may disclose this information at its sole discretion, but only as

long as all the parties involved have agreed to keep the information confidential at all times.

Page 1 of 5

Patient (unless a minor)

Discovery Health (Pty) Ltd administers the Discovery Health Medical Scheme Registration number 1997/013480/07 An...