Application for out-of-hospital management of a

Prescribed Minimum Benefit condition 2020

Who we are
Discovery Health Medical Scheme (referred to as 'the Scheme'), registration number 1125, is the medical scheme that you are applying to
become a member of. This is a not-for-profit organisation, registered with the Council for Medical Schemes.
Discovery Health (Pty) Ltd, registration number 1997/013480/07, (referred to as 'the administrator') is a separate company and an authorised
financial services provider and is the administrator and managed care organisation for Discovery Health Medical Scheme and takes care of the
administration of your membership.

Contact us
Tel (members): 0860 99 88 77, Tel (health partner): 0860 44 55 66, PO Box 784262, Sandton, 2146, www.discovery.co.za, 1 Discovery Place,
Sandton, 2196.
Purpose of the form
This form is to apply for out-of-hospital treatment of a Prescribed Minimum Benefit condition.

What you must do

You need to complete section 1 of this form. Fill in the form in black ink and print clearly, or complete the form digitally.
All relevant sections must be physically signed the patient and cannot be signed digitally. The main member and patient must sign and date
any changes.
Your healthcare professional must complete section 2.1, 2.2, 2.3, 2.4 and section 3 to apply for treatment for a Prescribed Minimum Benefit.
Please include detailed documentation to support your application.
Please fax this completed and signed form with any documentation to support this application to 011 539 2780 or email
PMB_APP_FORMS@discovery.co.za.
You will receive a letter informing you of our decision and the process you should follow.

1. Patient details

Title Initials

Surname

First name(s) (as per identity document)

Preferred name
D D M M Y Y Y Y
Gender F M Date of birth - -

ID or passport number Country of issue

Membership number Telephone (H) -

Telephone (W) - Cellphone -

Fax -

Email

Relationship to main member

The outcome of this application can be communicated to me by Email Fax

I give permission for my healthcare professional to provide Discovery Health Medical Scheme and Discovery Health (Pty) Ltd (as administrator)
with my diagnosis and other relevant clinical information required to review my application for Prescribed Minimum Benefits.
I understand that:
1.1. Funding from the Prescribed Minimum Benefit is subject to clinical entry criteria as determined by Discovery Health Medical Scheme.
1.2. Each case will be assessed on its own merit.
1.3. By registering for the Prescribed Minimum Benefits, I agree that my condition may be subject to disease management intervention and
periodic review and that this may include access to my medical records.
1.4. The covered Prescribed Minimum 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 Discovery Health Medical Scheme asks for this.
1.5. The covered Prescribed Minimum Benefit conditions and clinical entry criteria may change from time to time and I may need to send an

Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates. DHMAOM001
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised Page 1 of 3
financial services provider. 12.12.2019
 updated or new application form, if Discovery Health Medical Scheme asks for this.
1.6. Consent for processing my personal information
1.6.1. I give the Scheme and the administrator consent to have access to and process all information (including general, personal, medical
or clinical information) that is relevant to this application.
1.6.2. I understand that this information will be used for the purposes of applying for and assessing my funding request for Prescribed
Minimum Benefits.
1.6.3. I consent to the Scheme and the administrator disclosing, from time to time, information supplied to them (including general,
personal, medical or clinical information) to my healthcare provider, to administer the Prescribed Minimum Benefits.

D D M M Y Y Y Y
Signature of patient (if patient is a Date - -
minor, main member to sign).

Please only sign if information is true, complete and correct.

2. Application (healthcare professional to complete)

2.1. Application for acute and/or ongoing out-of-hospital medical management
Condition ICD-10 code Consultation or Motivation Quantity
procedure code**

*Please clearly specify what is required, for example consultations, pathology, radiology and/or procedure.

**The professional billing codes must be supplied for us to review the application.
Please attach any relevant supporting documents, for example pathology tests. Please supply a completed DSM IV or DSM V form including
the GAF (Global assessment of Functioning) score must be supplied for children below the age of 13.

2.2. Application for medicine

Current medicine required (please provide supportive clinical results or information)

Condition ICD-10 code Medicine name, strength and Number of months

dosage

2.3. Application for radiology

Condition ICD-10 code Medicine name, strength and Quantity per year
dosage

2.4. Application for pathology

Please note that this form expires on 31/03/2021. Up to date forms are always available on www.discovery.co.za under Medical Aid > Find documents and your certificates. DHMAOM001
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised Page 2 of 3
financial services provider. 12.12.2019
Condition ICD-10 code Description of investigation Quantity per year

3. Healthcare professional’s details (healthcare professional to complete)

Name and surname

BHF practice number

Speciality

Telephone - Fax -

Preferred method of communication

Email

D D M M Y Y Y Y
Date - -
Signature of Healthcare Professional

Please only sign if information is true, complete and correct.

Discovery Health Medical Scheme is a registered medical scheme and regulated by the Council for Medical Schemes (CMS). The CMS contact details are as follows:
Email: complaints@medicalschemes.com | Customer Care Centre: 0861 123 267 | Website: www.medicalschemes.com DHMAOM001
Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised Page 3 of 3
financial services provider. 12.12.2019