Imperial Motus Med

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Imperial Motus Med

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Forms

Membership

picture_as_pdf Application for membership

picture_as_pdf Change in membership details

picture_as_pdf Plan selection form

picture_as_pdf Form A: Affidavit for Registration of Common-law Spouse/Partner/Fiancée

picture_as_pdf Form B: Affidavit for Registration/Confirmation of Principal Member's Parent/Brother/Sister/Child/Other Dependant (over the age of 21)

picture_as_pdf Form C: Affidavit for Registration/Confirmation of Child (over the age of 25) that is a Student

picture_as_pdf Form F: Affidavit for Registration of Grandchild

picture_as_pdf Form G: Affidavit for Registration of Physically Disabled Dependant

picture_as_pdf Form H: Affidavit for Monthly Income of Pensioners

picture_as_pdf Form I: Transfer of membership following death

picture_as_pdf Form J: Affidavit for Registration of Stepchild (under the age of 21)

picture_as_pdf Form K: Affidavit for Registration of Natural Child (under the age of 21) with a Different Surname to Principal Member

picture_as_pdf Form L: Affidavit for Registration/Confirmation of Principal Member's Brother/Sister/Other Dependant (under the age of 21)

picture_as_pdf Form M: Continuation membership for pensioners

picture_as_pdf Form N: Affidavit for Deregistration of Common-Law Spouse/Partner/Fiancée

picture_as_pdf Debit order form

picture_as_pdf Member consent form

picture_as_pdf Employer application form

Programme Enrolment

picture_as_pdf Palliative Care Application Form

picture_as_pdf HIV YourLife Programme Application Form

picture_as_pdf Maternity Programme enrolment form

picture_as_pdf PMB application form

picture_as_pdf Integrated Care Programme application

Authorisations

picture_as_pdf Chronic medication advance supply request form

picture_as_pdf Chronic Medication Application Form

Required information

The Scheme's registered name

PG Group Medical Scheme
The main member and the patient treated

The main member's name and the name of the patient treated (main member or dependant) as registered and indicated on the membership card
Membership number

The Membership number as indicated on the membership card
The doctor's practice number

Doctors registration number on the Health Professions Council of South Africa
ICD-10 code(s)

This is a diagnosis code, eg."J11.1"
Signed Proof of Payment

Proof of payment signed by the member and indicated as 'PAID' (where applicable).

Required information

Your membership number

Your Medical Aid Membership Number on your card
The name and practice details of the admitting doctor

The Doctor who is to performing the procedure should provide this
The date of admission to hospital or clinic

Date at which the patient gets admitted or Procedure Date if it occurs on the same day
The name of hospital or clinic

The Doctor, Hospital or Clinic can provide
The medical condition

The Doctor who is to performing the procedure should provide this
The diagnosis / the ICD-10/ Procedure codes / The type of procedure

The Doctor who is to perform the procedure needs to provide
The expected length of stay

How long the patient is expected to stay in the Hospital / Clinic

1Basic Contributions
2Late Joiner Penalties

person

Main Member

person_add

Dependants

Adult Dependants

Minor Dependants

Basic Contributions R{{total}} CALCULATING...

Any subsidies paid by the employer in respect of qualifying continuation members will continue. Active principal members who are part of the bargaining sector will continue to receive the employer's subsidy in terms of their current legal employment agreement. Active principal members who have converted to total cost of employment (TCoE) remuneration packages, pay full contribution indicated above.

Pensioners and retirees' income (that is used to determine their income bands and contributions) is based on 50% of their last BPSA pensionable earnings before retirement. This amount is increased by the consumer price index (CPI) every year.

Are you joining the Medical Aid on the same date you are joining the company?

			Years without Medical Aid cover
1	Main Member
{{$index + 2}}	Adult Dependant

Years Without Medical Aid Cover

Up to the age of 21, a dependants cover is regarded as years without cover. Medical Insurances not registered to the Council of Medical Schemes are not regarded as credible cover. Medical cover overseas is also not regarded as credible cover.

Basic Contributions R{{total | number: 2}}

+ Late Joiner Penalties R{{addUpTotal(0,latejoiner_total_member,latejoiner_total_dependant) | number: 2}} CALCULATING...

Total Contributions R{{addUpTotal(total,latejoiner_total_member,latejoiner_total_dependant) | number: 2}} CALCULATING...

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