Wilmedpark.co.za

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

Huis Dokter / Referring Doctor:

Behandelende Dokter / Attending Doctor:

Diagnose / Diagnosis:

Hospitaal / Hospital:

Wilmed Park

Admission Date:

Diagnosis and Procedure Codes provided by Treating Doctor:

ICD10 Code (Diagnose Code):

BHF Code (Procedure Code):

Type of Assistance:

Magtiging Nommer / Authorisation Number:

Pasiënt Besonderhede / Patient Details

Van / Surname:

Titel / Title:

Voorletters / Initials:

Volle Name / Full Names

I.D. Nr / I.D. No.:

Geboortedatum / Date of Birth:

Paspoort Nr / Passport No.:

Nasionaliteit / Nationality:

Taal / Language:

Beroep / Occupation:

Allergieë / Allergies:

Woonadres / Residential Address:

Poskode / Postal Code:

Posadres / Postal Address:

Poskode / Postal Code:

Tel (H):

(W):

Cell:

e-Pos / e-Mail:

Hooflid se Werkgewer / Main Member Employer

Naam van Werkgewer / Employer Name:

Adres van Werkgewer / Employer Address:

Tel:

Kontak Nommer ingeval van Nood (Naasbestaande) / Emergency Contact Number (Next of Kin)

Naam & Van / Name & Surname:

Verwantskap / Relationship:

Adres / Address:

Tel:

Mediese Fonds Inligting / Medical Aid Information

Mediese Fonds Name / Medical Aid Name:

Mediese Fonds No / Medical Aid Nr:

Afhanklike Kode (Patiënt) / Dependant Code (Patient):

Voordeeldatum / Benefit Date:

Skema Plan / Scheme option:

Persoon Verantwoordelik Vir Rekening / Person Responsible for Account

Naam & Van / Name & Surname:

Beroep / Occupation:

Adres / Address:

Tel:

Posadres / Postal Address:

I.D. Nr / I.D. No:

e-Pos / e-Mail:

Vereiste Dokumente / Required Documents

Please upload following documents are required for your admission:

1. Patient’s ID or birth certificate.

2. Main member’s ID.

3. Both sides of the medical aid card.

4. All documents and reports supplied by your treating provider

A driver`s license will not be accepted as identification.
No exceptions will be made on any of the above requirements.

Laai asseblief die volgende dokumente op vir u toelating:

1. Pasient se ID of geboortesertifikaat.

2. Hoof lid se ID.

3. Albei kante van die mediese fonds kaart.

4. Alle dokumente en verslae wat deur u behandelende verskaffer voorsien word.

'n Bestuurslisensie word nie as identifikasie aanvaar nie.

Geen uitsonderings sal op enige van bogenoemde vereiste gemaak word.

Magtiging bly die lid se verantwoordelikheidAuthorisation remains the member's responsibility

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