Claim form

Please note:

Please attach all documentary evidence to support this claim at the bottom of this page, i.e. service provider account and medical aid statement. Image dimensions should not be more that 1440px wide and 900px high and not more than 2 megs in file size.

*  Mandatory fields.

SECTION 1 - PERSONAL DETAILS

Medical Aid Scheme *
Medical Aid Number *
Gap Cover Option
Gap Policy Number *
Title Mr Mrs Other
If other please specify
Initials *
First Name(in full) *
Surname *
Date of Birth *
Contact no *
Email *
Identity no *
Postal address
Postal code *
Comments

SECTION 2 - CLAIM DETAILS

Dependant No
Treatment Date *
Dependant First Name *
Dependant Date of birth *
Practice No *
Tariff Code *
Claim Amount *
Tariff Amount *
Admit Date *
Hospital Auth No *
Discharge Date *
Practice Name *

It is very important that the medical aid statement reflecting the claims submitted, the hospital account and the doctors statements are provided with this claim! If these documents are not attached it will be considered an invalid claim.

SECTION 3 - BANKING DETAILS

Please deposit the proceeds of this claim into the following bank account.

Bank
Branch
Account Number
Branch Code
Account Holder
Type of Account Cheque Savings Transmission Other
If other please specify

SECTION 4 - ATTACH DOCUMENTATION

Please note:

Claims cannot be processed without the following documentation:

- Doctors accounts relating to inhospital procedures.

- Medical scheme payment advice where accounts were paid.

- First two pages of hospital account or medical scheme payment advice where hospital account was paid.

- If the documents are password protected, please supply us with the password.

Password
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I declare that the aforegoing details are, to the best of my knowledge true, correct and complete: *
Please complete the sum. Enter your answer as a numeric value: *

As per the terms and conditions of this policy all the required information must be submitted to TRA within 3 months of the date of medical aid processing the claim after which the claim will be considered "stale".