Option selection Form

PLEASE NOTE: OPTION CHANGES CAN ONLY BE EFFECTIVE FROM 1 JANUARY EACH YEAR. ENSURE THAT THE FORM REACHES SIZWE HOSMED MEDICAL SCHEME BY 11 DECEMBER.I confirm that I have chosen to change options on the Scheme, and that this declaration is based on advice received fromSignature of memberDatePLEASE PRINT IN CAPITAL LETTERS. USE A BLACK PEN ONLY, PLEASE MARK APPROPRIATE CHOICE USING A CROSS (X).SECTION D: MEMBER DECLARATIONPLEASE COMPLETE APPROPRIATELY ALL THE SECTIONS BELOW IN FULL:

SECTION A: OPTION CHANGE

Kindly consider the enclosed brochure. Make your option selection and advise your employer as soon as possible. This form must be submitted to your payroll department, where applicable, for onward submission to the Scheme.

Reason for change (please tick appropriate)

Financial

Beneﬁts

Other

SECTION B: EMPLOYER DETAILS

Employer Name

Payroll no.

Employer Stamp

Employer Group Number

Date of Employment

Employer signature

Designation

Date

SECTION C: MEMBER DETAILS

Membership number

Name

Surname

Postal address

Address Line 1

Address Line 2

City

Zip Code

Tel. no. (h)

Work no.

Cell no.

Identity no

Race (please tick)

African

Coloured

Indian/Asian

White

SECTION D: MEMBER DECLARATION

I conﬁrm that I have chosen to change options on the Scheme, and that this declaration is based on advice received from

I conﬁrm that I have made the choice of option after considering my personal requirements and those of my dependants and have not been inﬂuenced in any way by Sizwe Hosmed Medical Scheme. I conﬁrm that to prevent the risk of concluding a transaction that is not appropriate to my needs, objectives and circumstances, I should obtain a full healthcare needs analysis.

To ensure that my application form is submitted to my employer for processing:

I agree to access www.hosmed.co.za to access full conditions and undertakings of the Scheme as a member of
Hosmed Medical Scheme.
Where applicable: Member Savings Account allocations will be pro-rated depending on the activation date.
The Scheme has the sole right to collect negative balances owed to the Scheme by the member even when
member has terminated from the Scheme.

Date

Fund Declaration

As Sizwe Hosmed Medical Scheme we are strongly committed to protecting your personal data. We are required by POPIA to explain why and how we collect, use, and disclose your personal information, which may include health and ﬁnancial information. Sizwe Hosmed Medical Scheme and its administrator (3Sixty Health (Pty) Ltd) will keep your information supplied to us in this application conﬁdential. Acceptance of these terms and conditions is a requirement for activation and servicing of your medical scheme membership. You give us consent to process your personal information for the following purposes:

Administration of your health care option;
Provision of managed care services to you;
Providing relevant information to a contracted third party;
To proﬁle and analyse risk;
For research purposes and;
To comply with legislation.

Please note that we will only share your information with a third party if you have granted us your consent for the disclosure of the information to such third party or if a contractual relationship exists in terms of which we are obliged to provide your information to such third-party. We may amend this notice from time to time, please check our website to inform yourself of any changes.