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Patient's First Name
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Age of Patient
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>65 years
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What is your Medical Diagnosis?
Background information and reason you are needing case management support?
Which Medical Aid are you on?
What is your Medical Aid number?
Main Member's full name?
ID number of Main Member?
Contact number of Main Member?
Contact Email of Main Member?
Treating Doctor's full name?
Email of treating doctor
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Please upload all supporting documentation related to your enquiry including Medical Aid Correspondance.
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Select an item (R)
Review of Medical Aid Correspondance - R350
Engage in dispute with Medical Aid - R850
Ex-Gratia application with Medical Aid - R2500
Preparation and Participation in Dispute Hearing with Medical Aid - R3000
Council for Medical Schemes Complaint (Preparation and Submission) - R3500
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