Your Online Claim Form

1) YOUR PROFILE
PRINCIPAL INSURED DETAILS
Title*
First Name*
Surname*
Identification Type*
ID Number*
Passport Number*
DOB*
Medical Scheme
Medical Scheme Option
BestMed Option*
Bonitas Option*
Compare Option*
Discovery Option*
Fedhealth Option*
Gems Option*
Genesis Option*
Hosmed Option*
LAHealth Option*
Keyhealth Option*
Liberty Option*
MediHelp Option*
MedShield Option*
Momentum Option*
Profmed Option*
Resolution Option*
SelfMed Option*
Sizwe Option*
SpectraMed Option*
TopMed Option*
Other*
Membership Number
Cellphone*
Telephone (H)
Telephone (W)
Email Address*
Email me a copy of my claim submission
*
- Yes
- No
PATIENT DETAILS
- I acknowledge that the below details are not required when the Principal Insured is the Patient
Title*
First Name(s)*
Surname*
Identification Type*
ID Number*
Passport Number*
DOB*
Relationship
Medical Scheme
Scheme Option
BestMed Option*
Bonitas Option*
Discovery Health Option*
Fedhealth Option*
Keyhealth Option*
Liberty Option*
MediHelp Option*
Momentum Option*
Resolution Option*
SpectraMed Option*
TopMed Option*
Other*
Membership Number

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