Magtiging bly die lid se verantwoordelikheid
Authorisation remains the member's responsibility

Wilmed Park
Diagnosis and Procedure Codes provided by Treating Doctor:
Pasiënt Besonderhede / Patient Details
Hooflid se Werkgewer / Main Member Employer
Kontak Nommer ingeval van Nood (Naasbestaande) / Emergency Contact Number (Next of Kin)
Mediese Fonds Inligting / Medical Aid Information
Persoon Verantwoordelik Vir Rekening / Person Responsible for Account
Required Documents