:

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i.2 applytneree!ai:lo. :as;- a! r'a a'. a' :a -a-a.a.'a.-'.

e3 advlseYou.egaron,lrneapp aaE?aa'a;:a:: :_ :r.:_ :_::::
c- naraq" the -Lrd,19 o'\o, b=-ea:i ' a.::-71':. i. :- :': ': . .'-'::
: YourpersonalandHealthlnformationmay;lsobeshareCr'ii-.r.!e.ai::'..'.-..'..'....':.--:-:-:::::::-' :::-.: :: i 'l
rearhlnforralonfo.Yo-rlmneoareredcal:'q::-e':*i)'c'-i':P-:-(:::. -'. "':-'- a..'-".::_.':_1_'
il. YoucanatanytimechangeorrevokeYourconsenitoca.rcpateonthef,hlS t,io-r=. '':'''..-'.a':'.-4."...'.-.::--.'.=::
,ou'oec(:ol.lrth5ca<e.voLrD-Do l'el-lS-. l oeaccessed1.. io'ta; :c- T,:'di(' a':',':-i;:,-:)'. :!'a - :r'::'
vrillnolongerdiscloseYourPersonaandl-leathLnfornratlontoanyofitsContractedThlrdPartesiortl-.c,'1c::ti'."i;-::-'':-:-:-:
you not receive the proper or correct treatment as a result of your Personal and Health lnfo rmation n ot being approPriately sha re d, yo"
Managed Health Care organisation against any liabiL;ty
11 youunderstandthatonceBontashassharedYourPersonalandHealthlnformationwithYourselectedheaLthcareptcvdersandBonlasacn:ra::.i:i'.'ar::: a:-:::-::
information and wili not be accountable for its safeguarding. You also understand that Your selected healthcare providers and Contracted Thlrd Fan es ha,e ccr'rr.z: -.:3:'
information private and confidential and in line wlth POPIA and the Applicable Data Protectlon Legislation.
PABT III

ACKNOWTEDGEM ENT AN D DECTARATIO N AUT}IO RISING BON ITAS AND MEDSCH EME TO ATTTEN D TO THIRD PARTY RECOVER IES FOR BONITAS MEMBERS ,

you for such lois or damage, all costs paid by Bonitas Medical Fund ("Bonitas" or "the Scheme") for Your treatment or the treatment of all You r Dependants.

third-party ctaim and that You will readily sign all documentation which may require Your signature by the scheme.

You and/or Your registered Dependants and may lead to the termination of Your membership.

hospital records/accounts, directly from the relevant departments or suppliers.

Last updated: 22 September 2022

Thjs version of the Terms and Conditions rcplace3 and supersedes all oiher ferms and Conditions that have been previously issued.

5rEnature of main member \it ,{5o.-s Date:

Declaration
1. l,theundersigned,applytobeadmittedasamemberofBonitasMedlcalFund.liaccepted,lagiee
that it will be provided to me upon my request to the Scheme. j_ :::
2 ldeclareandwdrrdnttharmyoeoerllr:s'ae.)-)e'I:dll )':-a::':--.:a.-:Le-s9:'::.': _ ' ""__ :n ro the Scheme and that I am in a position to provide written proof of
thelr consent and authority as suc: ic li-e Schere uDon request.
-:i-: --
3. ldeclarethatanyfalseinfornraionin:l'sappl.atonfoTncrtl'e'."-::aa!!reofanym;:!'. ''.'-='.:'
l. lacceptthatBonitashastherighrtcclairid:magesinrescecic'er-.ssaroafiagesitm3rs!:-.':-:::- -:--:::::-'.:
behaviourbymecranyofm;rdepend:nts fanycfmyormydeperd:r:scrc:nrstances613'1::'::':-i::-:-':r =":
Schemeofthechanges.lunderstandttatfaiiretodosomayleac:.:r.:.'r.atlon,oramar:-='--:':-.i:'-::-r:;:
Lr1ltec:J'ecl;rdj,,]r,o--:JL^)J::,.=:.E.-),pac:,-,:-
5.

to the Scheme

tta:a"a-a

-..'-..'...,r..:3.enritledtoanybenefitsarisingfrommymembershipaha:::ee'
--:.ar..:::r';.-:-:Schemeofanychangestomyormydependants'heathorpersofa::::-:r,:-'ll,i'"- a=ra:'.'.:-:-:.t:'.=--.:="'-''':
-::-::::-:a-a.a.,alr,,,andmydependants'healthcareserviceprovidersrodscoseal!ae's:r, -a::.-:i::1::'aaa:'"-":'-.
-.-.-..-:,:s:: l, r.-:ihercurrentorhistorical,totheScheme,itsadmlnistrator,itscontraa:agt..t..aa'.. i.:.'.:-::':::.-::::-:-:
.-.:.a-a-ta-taa:cae:j:.eTetouponrequest,providedthattheinformationanddocumentationist.eatra:!ll'=::-'.: aa:='ar'a',1'-:-:
-.a:......acc!!rtri0rmatlonbengdisclosedbytheirheatthcareserviceproviderstothe5cheme;tsad^ni:'r:r-;-::i::-:'::i::::
a n o ihai I am in a position to provide written proof of their consent as such to the Scheme upon request.

inf-o.mation,thattheSchememayreasonablyrequireforthepurposeofcarryingoutitsobligationsintermsoftheMedicalSchemesActNo 131of:'998a.dtheRules.
i2. lfuitheragreeandunderstanCthatlandmydependantsmayberequiredtoattendanexaminationbythescheme'smedicalassessorsfromtimeiotime.
:-3. ldeclareandwarrantthatlandmydependantsarenotregisteredasmembersand/ordependantsofanotherregisteredmedlcalscheme
14. I ufdersiand and acknowledge that the following underwiiting conditions may be applicable to my membership as pre5cribed by the Medical Schemes Act No. 131 of 1998:
' A 3 (Three) -month general waiting period in respect ofall benefits;
, A 12 {T}velve) -month exclusion in respect ofa pre-existing condition;
. A late-joiner coniribution penalty.

o. dtrand

Scheme and will be made available to me on request.

to time'
the Rules of Bonitas. I however acknowledge thai the contractual rights and obligations may be further varied through my ongoing interaction with Bonitas from time
I acknowledge that I have read and understind the contents ofthis application form and where necessary, have been explained to
19. me.

matters relating to the claims on my membership, and that I am in a position to provide written proof oftheir consent as such to the Scheme upon request.

oranyielevant goverhment authorities foradministrative andstatistical purposes,providedsuchinformationistreatedasconfidentialatalltimes.

Membership form.

sole and absolute discretion.

S :r;:.re of raln member Date: \1. - !+