a Member of GEMS
1. Read the application guide carefully, as it contains important information that will assist you in completing the application form correctly.
2. Complete the application form overleaf and ensure that you have included all relevant documentation as well as your signature where required.
3. Submit the form and supplementary documentation to GEMS in any of the following manners: Fax: 0861 00 4367 Email: enquiries@gems.gov.za Regional offices: Refer to the application guide for more detail Postal address: GEMS, Private Bag X782, Cape Town 8000
4. If your application is successful, GEMS will post a welcome pack to you within 7 days of receipt of your application.
5. Your application will be delayed if you do not provide GEMS with all the required documentation.
6. If your application could not be processed, GEMS will contact you within 5 days of receipt of your application.
Please contact our Call Centre on 0860 00 4367 or email enquiries@gems.gov.za if you require any further assistance with the completion of your application form.
Application
for Membership
PLEASE REFER to tHE APPLiCAtion GUiDE to ASSiSt YoU WitH tHE CoMPLEtion oF tHiS FoRM. Do not REtURn tHiS GUiDE WitH YoUR CoMPLEtED APPLiCAtion FoRM.
nnnnnnnnnnnnn or Passport number nnnnnnnnnnnnn Date of birth nnnnnnnn Nationality D D M M Y Y Y Y Gender n M n F Income tax number nnnnnnnnnn Marital status n Married n Single n Divorced n Widow/er n Co-habiting
Postal address
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n Sapphire
n Beryl
n Ruby
n Emerald
n Onyx
All claim refunds are made at the Scheme rate and in accordance with the Scheme rules.
nnnnnnnn D D M M Y Y Y Y Please indicate the date on which you would prefer to join GEMS nnnnnnnn
Please indicate the date on which you started at your current employer D D M M Y Y Y Y
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n Yes n No If yes, are you the principal member or a dependant? n Member n Dependant
Are you a member or dependant of a registered medical scheme? If you are a member/dependant of another scheme, please attach your certificate of membership from your previous medical scheme that confirms the end date (membership cards are not sufficient). You must ensure that your membership on your current medical scheme is cancelled before being covered by GEMS. Name of previous medical scheme Member number Period of membership From D D M M Y Y Y Y
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To D D M M Y Y Y Y
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If you choose to pay via debit order you need to complete Section H: Member banking details below. If you choose to pay cash, please use the following banking details when depositing your contribution: Bank: FNB Branch Code: 204109 Account Name: Government Employees Medical Scheme Account Number: 62094049593 Reference: Member number
Date of signature D D M M Y Y Y Y
Authorised signature
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SECtion i: ConSEnt
Being duly authorised, my dependant/s and I hereby authorise the medical practitioner and/or staff member of the hospital in whose care I am/my dependants are or my healthcare provider or any other person in possession of any information concerning my health or that of any of my dependants to supply: i. Any information that GEMS, its agents and/or contracted third parties need in order to settle any claim submitted by me or my dependant/s to GEMS and/or its agents; ii. GEMS and/or its agents case manager with any information the case manager needs in order to manage services rendered to me or my dependant/s; iii. The healthcare management with any information, on an anonymous basis, that is required for administrative and statistical purposes, provided such information shall be treated as confidential at all times. it is important to give GEMS and/or its agents your consent to negotiate with your doctor/s, hospital or any other healthcare provider in order to ensure that you receive optimal care, that is cost effective.
Date D D M M Y Y Y Y
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SECtion J: DECLARAtion
I declare that: The content of this form is true, correct and complete. Should there be any non-disclosure or material misrepresentation, I understand that my membership may be terminated and I may be required to refund the Scheme, any sum which, for my abuse of the benefits or privileges of the Scheme, would not have been disbursed on my behalf, subject to appeal procedures. I have made my option choice and I have satisfied myself with the benefit structure and contributions under this option. I agree to familiarise myself with the rules of the Scheme. My beneficiaries, with the exception of my spouse/partner, are fully or partially dependent on me and to the extent that they are partially dependent on me do not receive an annual income more than the maximum social pension amount applicable or they are not permanently employed at the date of signing this form. I am aware that GEMS may impose general and/or condition-specific waiting periods, as provided for in the Medical Schemes Act (131 of 1998). I understand that my personal details and medical information (obtained from healthcare providers with my explicit consent) shall be kept confidential. I am aware that my and my dependants confidential health and personal information may be used for research, statistical data, managed care and reporting purposes and any deviation from this constitutes a breach of confidentiality. I understand that in the event that GEMS wishes to use my or my dependants confidential information for purposes other than those outlined in this declaration, GEMS is required to obtain further consent from me and my dependants. I understand that my personal and health related information will not be used for purposes of related business nor sold for commercial purposes. I understand that GEMS has granted access to certain persons within the organisation and its contracted third parties to members personal and health related information. I understand that GEMS and its contracted third parties will use the medical/health/diagnosis/procedure information provided for the following purposes: processing the application for membership, re-imbursement of claims, determining member entitlement to benefits and risk management practice. Name and surname
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Guide to Completing
We have highlighted the important information in the various sections of your application form that will assist you in completing your application form correctly. Please read the guide carefully.
Please make sure that you also supply the following supplementary documentation for the Principal Member: 1. Copy of ID for Principal Member 2. M2 form which is to be submitted with application form when you need to change your medical scheme particulars and to continue receiving your same subsidy 3. Z583 forms if you are retiring and need to apply for continuation of membership or if you are a dependant who needs to continue membership upon the death of the Principal Member 4. Subsidy confirmation letter from National Treasury, if available 5. Membership certificate from the previous medical scheme with an end date 6. Your signature where required (Sections H, I and J)
Ex-spouse
Partner
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Child in-law
Children of sibling
note
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Adult dependant rates are payable for all dependants over the age of 21, excluding - Disabled dependants (child rates are payable); - Children who are students (child rates are payable until the age of 27); Please note that your adult dependant/s may be subject to an annual eligibility review. Members must provide annual proof of dependency of all beneficiaries over the age of 21 (excluding disabled dependants). The affidavits mentioned in the table above, as well as the medical questionnaire for disabled dependants, are available on the GEMS website at www.gems.gov.za or can be obtained by phoning the Call Centre on 0860 00 4367. What you need to do if you have to provide GEMS with the following documents: Affidavits If you have to submit an affidavit you need to go to your nearest police station or any person authorised as a commissioner of oaths to certify that the information you are providing to GEMS is true and correct. Medical report Take the Assessment Report by Medical Practitioner (Disability) Form to the applicable medical practitioner and request him/her to complete the form. The consultation will be covered from the GP consultation benefit for registered members. Unregistered members are required to cover the cost of this consultation out of their own pockets.
What you need to do if you belonged to a previous medical scheme prior to joining GEMS: Please contact your previous medical scheme and request them to provide you with a membership certificate with an end date as proof of membership. Please note that if your membership certificate does not reflect an end date, we are unable to use it. Remember to complete and forward a termination letter to cancel your membership with the previous medical scheme, if you have not done this yet. If you are unable to obtain a membership certificate, we will accept a termination of membership letter on your previous medical schemes letterhead, as proof of resignation.
SECtionS G AnD H
It is compulsory to complete these sections in full, as your application form will not be processed if banking details are not provided.
SECtionS i AnD J
Please ensure that you read these sections carefully before you sign these sections on your application form. Please note: Your application form will not be processed without your signature.
FRiEnDS oF GEMS
GEMS has partnered with thousands of doctors, dentists and other healthcare service providers to offer members an innovative provider registry that brings healthcare providers within members reach. These providers have agreed not to charge GEMS members above the Schemes rate, which means that you do not have to pay anything out of your own pocket for a consultation with a Friend of GEMS. To find a Friend of GEMS in your area, simply send an SMS to 33489 with your member number, the service provider category, the suburb and/or extension and town you require. For example if you live in Hillcrest, Pretoria and you need to see a general practitioner (GP), your SMS should look like this: 123456789, GP, Hillcrest, Pretoria. You will receive an instant response with the details of the providers, for example Dr A Dlamini, 103 Kingsley Centre, Church Street, 0121234567. SMSes are competitively priced at R1.50 and the response SMS is included. this service applies to all options.
HiV/AiDS
If you or any of your dependants are living with HIV/AIDS, it would be in your interest to join the GEMS HIV/AIDS Management Programme by calling Aid for AIDS on 0860 100 608. This is a confidential programme, neither the employer nor the Scheme has access to the participants information.
CHRoniC MEDiCAtion
Chronic medicines are prescribed to treat ongoing conditions such as high blood pressure or asthma and are taken continuously. GEMS provides comprehensive chronic medicine benefits to all members. In order to qualify for your chronic medicine you have to register on the Medicine Management Programme, after you have received notification that you are a registered member of GEMS. Chronic medicines include: Medicine for life-threatening illnesses, like diabetes; Medicine used on an ongoing basis to treat disabling chronic illnesses that significantly affect productivity and quality of life; and Expensive short-term medicine that will prevent other expensive treatment, like hospitalisation. 4 of 6
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