Please contact our Call Centre on 0860 00 4367 or email [email protected] if you require any further assistance with the completion of your application form. 1. Read the application guide carefully, as it contains important information that will assist you in completing the application form correctly. 2. Complete the application form overleaf and ensure that you have included all relevant documentation as well as your signature where required. 3. Submit the form and supplementary documentation to GEMS in any of the following manners: • Fax: 0861 00 4367 • Email: [email protected]• Regional offices: Refer to the application guide for more detail • Postal address: GEMS, Private Bag X782, Cape Town 8000 4. If your application is successful, GEMS will post a welcome pack to you within 7 days of receipt of your application. 5. Your application will be delayed if you do not provide GEMS with all the required documentation. 6. If your application could not be processed, GEMS will contact you within 5 days of receipt of your application. Quick Guide to Becoming a Member of GEMS
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Please contact our Call Centre on 0860 00 4367 or email [email protected] if you require any further assistance with the completion of your application form.
1. Read the application guide carefully, as it contains important information that will assist you in completing the application form correctly.
2. Complete the application form overleaf and ensure that you have included all relevant documentation as well as your signature where required.
3. Submit the form and supplementary documentation to GEMS in any of the following manners:
Gender n M nFIncometaxnumbernnnnnnnnnnMarital status n Married n Single nDivorced nWidow/er n Co-habiting
Postaladdress
Code
Residential address
Code
Telno(H)() (W)()
Cellphone Faxno()
Email
D D M M Y Y Y Y
Name and surname 1of6
PLEASE REFER to tHE APPLiCAtion GUiDE to ASSiSt YoU WitH tHE CoMPLEtion oF tHiS FoRM. Do not REtURn tHiS GUiDE WitH YoUR CoMPLEtED APPLiCAtion FoRM.
PLEASE CoMPLEtE ALL tHE APPLiCABLE SECtionS CAREFULLY AnD in FULL.
Ensure that you provide all necessary supplementary documentation. Submit the completed application form to GEMS in any of the following manners:
Viafaxto0861004367,or [email protected],or Via regionaloffices, or Postaladdress:GEMS,PrivateBagX782,CapeTown8000
Applicationfor Membership
FoR oFFiCE USE onLY
SECtion B: DEtAiLS oF DEPEnDAnt/S
PleaserefertoSectionBoftheapplicationguideinordertoensurethatthosepersonsyouwishtonominateasyourdependant/squalifyassuch.We cannot process your form if iD details are not provided. it is therefore compulsory to complete this section in full.
Surname Full first name Gender Date of birth iD or passport number
Are you a member or dependant of a registered medical scheme? nYesn No
Ifyes,areyoutheprincipalmemberoradependant?n Member nDependant
If you are a member/dependant of another scheme, please attach your certificate of membership from your previous medical scheme that confirms the end date (membership cards are not sufficient). You must en-sure that your membership on your current medical scheme is cancelled before being covered by GEMS.
Name of previous medical scheme
Member number
PeriodofmembershipFromnnnnnnnn Tonnnnnnnn
SECtion G: MEtHoD oF PAYMEnt Active employees’ monthly contributions are deducted automatically from their salaries where applicable.
Pensioner members, please select only one payment method from the list below:
Bank:FNBBranchCode:204109Account Name: Government Employees Medical SchemeAccountNumber:62094049593Reference: Member number
SECtion H: MEMBER BAnkinG DEtAiLS
Bank account details required for the direct crediting of member refunds and the direct debiting of amounts due by me to the Scheme. We cannot process any refunds due to you should we not have your banking details on record.
Bankaccountnumber Nameofaccountholder
Nameofbank
Branchname Branchcode
Typeofaccount n Current n Savings nTransmission
Dateofsignaturennnnnnnn
Authorisedsignature Fullname
D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
SECtion i: ConSEnt
Beingdulyauthorised,mydependant/sandIherebyauthorisethemedicalpractitionerand/orstaffmemberofthehospitalinwhosecareIam/mydependantsareormyhealthcareprovideroranyotherpersoninpossessionofanyinformation concerning my health or that of any of my dependants to supply:
i. AnyinformationthatGEMS,itsagentsand/orcontractedthirdpartiesneedinordertosettleanyclaimsubmittedbymeormydependant/stoGEMSand/oritsagents;
ii. GEMSand/oritsagents’casemanagerwithanyinformationthecasemanagerneedsinordertomanageservicesrenderedtomeormydependant/s;
iii. Thehealthcaremanagementwithanyinformation,onananonymousbasis,thatisrequiredforadministrativeandstatisticalpurposes,providedsuchinformationshallbetreatedasconfidentialatalltimes.
it is important to give GEMS and/or its agents your consent to negotiate with your doctor/s, hospital or any other healthcare provider in order to ensure that you receive optimal care, that is cost effective.
Mybeneficiaries,withtheexceptionofmyspouse/partner,arefullyorpartiallydependentonmeandtotheextentthattheyarepartiallydependentonmedonotreceiveanannualincomemorethanthemaximumsocialpension amount applicable or they are not permanently employed at the date of signing this form.
Iamawarethatmyandmydependants’confidentialhealthandpersonalinformationmaybeusedforresearch,statistical data, managed care and reporting purposes and any deviation from this constitutes a breach of confidentiality.
IunderstandthatintheeventthatGEMSwishestousemyormydependants’confidentialinformationforpurposes other than those outlined in this declaration, GEMS is required to obtain further consent from me and my dependants.
Iunderstandthatmypersonalandhealthrelatedinformationwillnotbeusedforpurposesofrelatedbusinessnor sold for commercial purposes.
IunderstandthatGEMShasgrantedaccesstocertainpersonswithintheorganisationanditscontractedthirdparties to members’ personal and health related information.
IunderstandthatGEMSanditscontractedthirdpartieswillusethemedical/health/diagnosis/procedureinformation provided for the following purposes: processing the application for membership, re-imbursement of claims,determiningmemberentitlementtobenefitsandriskmanagementpractice.
Name and surname 4of6
D D M M Y Y Y Y
Name and surname 5of6
SECtion J: DECLARAtion ContinUED IunderstandthatGEMShasenteredintoconfidentialityagreementswithallcontractedthirdpartieswhohaveaccesstobeneficiaryinformationforthepurposesofdatatransferandmanagement,schemeadministrationand managed care arrangements.
Iherewithirrevocablyauthorisemyemployer/GEMStorecoverfrommysalary/bankaccountanyamountImaylegally owe GEMS and to pay over to GEMS or its agents all amounts thus recovered.
IacknowledgethatIamawarethatGEMSmayinstitutedebtmanagementactivities,asprovidedforintherulesoftheScheme,againstmeintheeventthatIdefaultonthepaymentofcontributionsoranyotheramounts due to GEMS.
Member information (personal and health information) will not be used for purposes of related company business nor sold for commercial purposes.
Therearedatasecuritymeasuresinplace.
Access is granted to persons within the organisation and its contracted third parties, to the personal and health informationofbeneficiaries.
TheSchemeanditscontractedthirdpartieswillusethemedical/health/diagnosis/procedureinformationprovided for the following purposes: processing the application for membership, re-imbursement of claims, determiningmemberentitlementtobenefitsandriskmanagementpractice.
TheSchemehasensuredthatconfidentialityagreementshavebeenenteredintowithallcontractedthirdpartieswhohaveaccesstobeneficiaryinformationforthepurposesofdatatransferandmanagement,Schemeadministration and managed care arrangements.
Intheeventofabreachofconfidentiality,theSchemeassumesresponsibilityandthebreachwillbemanagedaccording to the Scheme’s internal protocols.
Please call 0860 00 4367 should you not have received confirmation of your membership on GEMS within7 working days from the date of submission of your application.
Name and surname 6of6
Postal address:GEMS,PrivateBagX782,CapeTown8000
Please do not return this guide with your completed application form.
We have highlighted the important information in the various sections of your application form that will assist you in completing your application form correctly. Please read the guide carefully.
Please make sure that you also supply the following supplementary documentation for the Principal Member:
1.CopyofIDforPrincipalMember2. M2 form which is to be submitted with application form when you need to change your medical scheme
particulars and to continue receiving your same subsidy3.Z583formsifyouareretiringandneedtoapplyforcontinuationofmembershiporifyouareadependantwhoneedstocontinuemembershipuponthedeathofthePrincipalMember
EmployerPleaseindicateyourcurrentemployer’snameandorganisationcode.Yourorganisationcodecanbeobtainedfromyour salary advice, if you are a civil servant.
SECtion B: DEtAiLS oF DEPEnDAnt/SPleasecompletethedetailsofyourdependant/sinSectionBoftheapplicationform.
it is compulsory to complete the iD details of your dependants in this section. We will be unable to process your application if this information is not provided.
Spouse Completed dependant section on application form.•Ifcustomarymarriage,anaffidavitfromthememberconfirmingtheobligation•towards the spouse.MarriagecertificaterequiredifmarriedandsurnamediffersfromPrincipalMember.•
Ex-spouse Completed dependant section on application form.•Copy of legal obligation to provide medical support per divorce settlement or court •ordertosucheffectexisting.
Guide to Completingand Submitting Your Application Form
DESCRiPtion oF DEPEnDAnt DoCUMEntAtion REqUiRED
Child (biological, adopted, step or foster),withPrincipalMember’ssurname, under the age of 21
Completed dependant section on application form.•note:Ifthechild’ssurnamediffersfromthePrincipalMember’s,anaffidavitconfirmingtheobligationtowardsthechildandstatingthereasonforthedifferenceisrequired.(SwornaffidavittobecompletedbyPrincipalMember)note:• Thespousemustberegisteredtoaddthestepchild.
Child (biological, adopted, step or foster), over the age of 21
Completed dependant section on application form.•Ifchildisastudent:•Proofoffull-timeregistrationatarecognisedtertiaryinstitutionand -AffidavitfromPrincipalMemberconfirmingfinancialdependency. -
Ifchildistotallydependentduetomentalorphysicaldisability:•Proofofdisabilityfromamedicalpractitioner(Medicalassessmentreporttobe -completedbyMedicalPractitioner)andAffidavitfromPrincipalMemberconfirmingfinancialdependencyandthatthe -child is not in a state institution.
Child in-law Completed dependant section of the application form.•AffidavitfromPrincipalMemberconfirmingfinancialdependencyofthe•beneficiaries.note:• Thechildofthememberorthememberorthemember’sspousemustberegistered to add the child in-law.
Completed dependant section on application form.•AffidavitfromPrincipalMemberconfirmingfinancialdependencyofthe•beneficiaries.note: • Parents-in-lawandgrandparents-in-lawmayonlyberegisteredifthespouseisalsoregisteredasabeneficiary.
Grandchild, great grandchild and so forth
Completed dependant section of the application form.•ProofofchildsupportgrantreceivedbythePrincipalMemberorthespouse,or•SwornaffidavitconfirmingfinancialdependencyofthegrandchildonthePrincipal•Member.(SwornaffidavittobecompletedbyPrincipalMemberandbiologicalparent, where applicable)note:• IftheparentofthechildisalsoregisteredasadependantanaffidavitisneededfromthePrincipalMemberforthegrandchildorgreatgrandchildonly.
Sibling, half sibling, step sibling and in-law sibling
Completed dependant section of the application form.•SwornaffidavitconfirmingfinancialdependencyofthesiblingonthePrincipal•Member.(SwornaffidavittobecompletedbyPrincipalMember)note: • ThesiblingofaPrincipalMemberorthePrincipalMember’sspousemayberegisteredasabeneficiary.note:• Thespousemustberegisteredtoaddhis/hersiblings.
Children of sibling Completed dependant section of the application form.•Swornaffidavitconfirmingfinancialdependencyofniece/sand/ornephew/sonthe•PrincipalMember.(SwornaffidavitmustbecompletedbythePrincipalMemberand sibling, where applicable)note:• ThechildrenofasiblingofaPrincipalMemberorthePrincipalMember’sspousemayberegisteredasabeneficiary.note:• IftheparentofthechildisalsoregisteredasadependantanaffidavitisneededfromthePrincipalMemberfortheniece/nephewonly.
note ID documents or birth certificates are required for all dependants.•
The affidavits mentioned in the table above, as well as the medical questionnaire for disabled dependants, are available on the GEMS website at www.gems.gov.za or can be obtained by phoning the Call Centre on 0860 00 4367.
What you need to do if you have to provide GEMS with the following documents:
commissioner of oaths to certify that the information you are providing to GEMS is true and correct.
Medical report TaketheAssessmentReportbyMedicalPractitioner(Disability)Formtotheapplicablemedicalpractitionerandrequesthim/hertocompletetheform.TheconsultationwillbecoveredfromtheGPconsultationbenefitforregisteredmembers.Unregisteredmembersarerequiredtocoverthecostofthisconsultationoutoftheirownpockets.
Please take note of the following: Youradmissiondatemustbeonthefirstdayofamonth. Where possible, ensure that your admission date at GEMS directly follows the cancellation date of your previous medicalscheme,asabreakinmembershipmaynegativelyimpactonyouremployersubsidy. Ifnodateisentered,yourregistrationdatewillbeautomaticallydeterminedforthefirstdayofthenextmonthsothat no arrear contributions are created. Ifthejoiningdateselectedbyyoucausesarrearcontributions,itwillbedeductedfromyoursalaryorbankaccount (where applicable). Inrespectofnewemployees,yourregistrationdatecannotbeearlierthanyourappointmentdate.
SECtion E: inCoME CAtEGoRYPensioner ApplicantsPleasefillinanM2formandZ583formforconfirmationofsubsidywiththeNationalTreasuryDepartment.TheseformscanbeobtainedfromtheGEMSwebsiteatwww.gems.gov.zaorbycallingtheCallCentreon0860004367.ShouldyouhaveacopyofaNationalTreasuryletterconfirmingyoursubsidy,pleaseattachittotheapplicationform,asitwillallowforamoreefficientregistrationprocess.
SECtion F: PREVioUS MEDiCAL SCHEME MEMBERSHiPPleaseattachamembershipcertificatewithanenddatefromyourpreviousmedicalscheme.
Please note the following: Legislationdeterminesthatyouoryourdependantsmaynotberegisteredontwomedicalschemesatthesame
time.3of6
What you need to do if you belonged to a previous medical scheme prior to joining GEMS: Pleasecontactyourpreviousmedicalschemeandrequestthemtoprovideyouwithamembership certificate
with an end date as proof of membership. Pleasenotethatifyourmembershipcertificatedoesnotreflectanenddate,weareunabletouseit.Remember
to complete and forward a termination letter to cancel your membership with the previous medical scheme, if you have not done this yet.
Ifyouareunabletoobtainamembershipcertificate,wewillacceptaterminationofmembershipletteronyourprevious medical scheme’s letterhead, as proof of resignation.
SECtionS G AnD HItiscompulsorytocompletethesesectionsinfull,asyourapplicationformwillnotbeprocessedifbankingdetailsare not provided.
SECtionS i AnD JPleaseensurethatyoureadthesesectionscarefullybeforeyousignthesesectionsonyourapplicationform.
Please note: Your application form will not be processed without your signature.
FRiEnDS oF GEMSGEMS has partnered with thousands of doctors, dentists and other healthcare service providers to offer members aninnovativeproviderregistrythatbringshealthcareproviderswithinmembers’reach.Theseprovidershaveagreed not to charge GEMS members above the Scheme’s rate, which means that you do not have to pay anything outofyourownpocketforaconsultationwitha“FriendofGEMS”.
ForexampleifyouliveinHillcrest,Pretoriaandyouneedtoseeageneralpractitioner(GP),yourSMSshouldlooklikethis:123456789,GP,Hillcrest,Pretoria.Youwillreceiveaninstantresponsewiththedetailsoftheproviders,forexample“DrADlamini,103KingsleyCentre,ChurchStreet,0121234567”.SMSesarecompetitivelypricedatR1.50andtheresponseSMSisincluded.this service applies to all options.
HiV/AiDSIfyouoranyofyourdependantsarelivingwithHIV/AIDS,itwouldbeinyourinteresttojointheGEMSHIV/AIDSManagementProgrammebycallingAidforAIDSon0860100608.Thisisaconfidentialprogramme,neithertheemployer nor the Scheme has access to the participant’s information.
GEMSprovidescomprehensivechronicmedicinebenefitstoallmembers.InordertoqualifyforyourchronicmedicineyouhavetoregisterontheMedicineManagementProgramme,afteryouhavereceivednotificationthatyou are a registered member of GEMS.
Sapphire and BerylIfyouareontheSapphireorBeryloption,yourGEMSNetworkdoctor,afterconfirmingyourdiagnosis,willberesponsible for registering your condition with GEMS and obtaining authorisation for your chronic medication.
Ruby, Emerald and onyxIfyouareontheRuby,EmeraldorOnyxoption,youneedtoapplyforyourchronicmedicinebyobtainingaChronicMedicineBenefitApplicationFormfromtheGEMSCallCentreordownloadingonefromourwebsiteat www.gems.gov.za.
Onceyourdoctorhasexaminedyouandcompletedtheapplicationform,youneedtofaxtheformtogetherwitharepeatabledoctor’sprescriptionto0866518009forprocessing.AlternativelyyoumayemailthesetochronicDSP@gems.gov.za.Alwaysensurethatyourapplicationhasbeenfilledoutcompletelyandsignedbybothyourself and your doctor.
A clinical team will then review your details and if necessary will contact your doctor (either telephonically or in writing)inordertoselectmoreappropriateand/orlesscostlymedication.AnSMSwillbesenttoyouindicatingthestatusofyourapplication(receiptandapproval).Yourrequestwilltakeapproximatelysevenworkingdaystoprocess.
Please remember the following when applying for chronic medicine: A separate chronic application form has to be completed for each family member who needs chronic medicine. Keepacopyofyourcompletedformforyourownrecords. Attachsupportingtests/specialinvestigationsandmotivations(asrequired)topreventdelaysintheprocessingof your application.
Ifyourapplicationisdeclined,aletterwillbesenttoyouandacopywillbesenttoyourprescribingdoctor.Iffurther clinical information is required, your request will be reconsidered once all the relevant information has been receivedfromyourdoctor.Yourdoctormaycall0860100608forassistance.
Uponprocessingofyourapplicationform,youwillreceiveanSMStoconfirmreceiptofyourapplication.Youwillbeinformed accordingly should any additional documents be required to complete the registration of your application.
Uponcompletionoftheregistrationofyourapplicationform,amemberpackthatincludesyourmembershipcardsand a comprehensive member guide will be posted to your postal address.