ANGLO MEDICAL SCHEME EX-GRATIA APPLICATION FORM

ANGLO MEDICAL SCHEME EX-GRATIA APPLICATION FORM
Please complete all sections and forward to the Ex-Gratia Department for preparation and submission to the Ex-Gratia Committee:
Postal Address: Ex-Gratia Department,
P.O. Box 652509,
Benmore, 2010
Fax Number: 011 539 1021
Email address:
ex-gratia@angloms.co.za
WHAT IS EX-GRATIA?
Ex-Gratia means “as a favour”. It is a discretionary consideration by Anglo Medical Scheme, which is only made where the Committee believes that
an exceptional situation exists which warrants funding. It is not a benefit that the Scheme has to offer, nor is funding guaranteed.
HOW ARE EX-GRATIA DECISIONS MADE?
The Ex-Gratia Committee reviews the ex-gratia application, which should be completed by the member asking for funding.
Only applications with complete information can be reviewed by the Committee. It is your responsibility to make sure that all the relevant information
is on the application form and attached to it. This will be presented to the Committee.
HOW DO I APPLY FOR EX-GRATIA?
The application form and all attachments need to be signed by the member. Please complete the application form in full, attaching all the relevant
information.
Fax the completed form and attachments to 011 539 1021 or email it to ex-gratia@angloms.co.za
I,
(please print your name and surname)
agree that by applying for ex-gratia, I accept that:
• The Committee’s decision is made according to the merits of each individual case and may not be used to justify a similar decision in future.
• Any decision the Committee makes is based on the information I have supplied.
on
Signed at (town or city)
Signature of main applicant
Y
Y
Y
Y
M
M
D
D
The main applicant must sign and date any changes
IMPORTANT – PLEASE NOTE
• Ex-Gratia awards may be made by the Committee in its absolute discretion, provided it is satisfied that significant financial hardship or exceptional
medical circumstances exist.
• The case will not be submitted to the Committee should any section be incomplete unless stated as not applicable.
• Financial disclosure for Frail Care and Dental cases as well as cases based on financial hardship is a requirement.
• Please note that all documentation should be submitted a month before the meeting as the cut off for preparation is two weeks before a scheduled
meeting date.
The following supporting documentation will need to be provided as a minimum requirement to review your application (please tick the appropriate
block to confirm it has been enclosed):
 Additional clinical information
 Account/s (if applicable)
 Quotes (if applicable)
 Proof of income for the principal member (refer to section for employer completion)
Please provide a short summary of your request with the exceptional circumstances to be considered below:
Page 1 of 4
Anglo Medical Scheme: PO Box 652509 Benmore 2010 | Tel: 0860 222 633 Fax: 011 539 1015 | Email: member@angloms.co.za | Website: www.angloms.co.za
Basis of request: (please tick)  Financial hardship Benefit Option: (please tick)


Managed Care Plan 
Exceptional circumstances 
Both
Standard Care Plan
Value Care Plan

MEMBER DETAILS
Membership Number
Main Member Name
Name of Patient
Number of Dependants Age of Dependants
Join Date on Scheme
D
D
M
M
Y
Y
Y
Y
Join Date on Plan
D
D
M
M
Y
Y
Y
Y
Tel Number (H)
Tel Number (W)
Cell Number
Fax Number
Postal Address
Postal Code
HOW WE CAN COMMUNICATE THE DECISION TO YOU
Telephone c Fax c Email c Post c
Details of above
MEDICAL REPORT TO BE COMPLETED BY PRACTITIONER
Diagnosis:
Medical and Surgical History:
Treatment Plan and Medication required (Please attach invoices or quotation. Approximate figures will not be accepted):
Doctors assessment and exceptional circumstances to consider:
Page 2 of 4
PRACTITIONER DETAILS
Practitioner Name
Practice Number
Contact Number
Signature
D
D
M
M
Y
Y
Y
Y
EMPLOYER/PENSION FUND DISCLOSURE
IMPORTANT – PLEASE NOTE
• Financial disclosure form to be completed in cases of financial hardship and applications for Frail Care and Dentistry services.
• Should the Pension Fund Administrator not be available, a copy of a recent Pension Slip or Tax Return will be accepted.
Name of Company
We confirm that receives a Gross Salary of
is employed by us and
per month.
RECOMMENDATION AND MOTIVATION BY EMPLOYER/PENSION ADMINISTRATOR:
Signature
Name of Officer
Designation
Company Stamp
Page 3 of 4
Date
D
D
M
M
Y
Y
Y
Y
MEMBER – FINANCIAL DISCLOSURE
Income and Expenditure
Value
Monthly Income after Tax
Salary/Pension (combined family Income)
R
Other Income
R
Total Income (A)
R
Monthly Expenditure
Bond/RentR
Loan Repayments
R
Municipal Rates & Taxes
R
Water & Electricity
R
Medical Aid Contributions
R
Insurance Premiums
R
Children’s Education
R
Hire Purchase Repayments (please specify)
1.R
2.R
3.R
GroceriesR
Domestic Assistance
R
TelephoneR
Transport/PetrolR
Other Expenditure (please specify):
1.R
2.R
3.R
Total Expenditure (B)
Net Income (A - B)
Statements of Assets and Liabilities
Assets (please specify)
R
R
Residential Property/Properties
1.R
2.R
Shares and Investments (please specify):
1. Shares
R
2. Investments
R
3. Other
R
Total Assets
Liabilities
Bank Overdraft/Other
R
R
STATEMENT BY MEMBER
I,
(full names) being the principal member,
hereby:
1. Declare that the information I have supplied on this application form is true and, to the best of my knowledge, complete.
2. Authorise the Scheme to obtain and disclose any medical information and history it may require in order to consider and process this apllication.
Page 4 of 4
Date
WAL_154DIH_V4_6/1/14
Signature of applicant