CASE MANAGEMENT FORM | Rare Diseases SA

registration

case

management

Patient's First Name

Patient's Last Name

Patient's Email

Patient's Contact Number

Patients' Address

Patient's Birthday

Patient's Gender

Patient's Home language

Age of Patient

What is your Medical Diagnosis?

Background information and reason you are needing case management support?

Which Medical Aid are you on?

Please specify your selected medical aid plan type

What is your Medical Aid Number?

Main Member Full Name

ID Number of Main Member:

Contact Number of Main Member:

Contact Email of Main Member:

Treating Doctor's full name:

Doctor's address:

Doctor's Email

Doctor's Phone

Please upload all supporting documentatio related to your enquiry including Medical Aid correspondance

Upload File

Please note that by clicking submit, you acknowledge that you are sharing confidential information with RDSA and accept RDSA's privacy policy and disclaimer. Privacy Policy: Rare Diseases South Africa (RDSA) respects your privacy and is committed to protect the personal information that you share with us. Our database contains private information including name, address, contact information and medical information. If you provide any private or non-public information it will be restricted to site administrators and individuals on a need-to-know basis and will not be sold or given outside of RDSA without consent from you. Disclaimer: RDSA is a resource for sharing information and support. RDSA members, employees and executive board members do not offer medical advice. The information provided on the RDSA website, newsletter and message board are designed to support, not replace, the relationship that exists between a patient/RDSA member and his/her physician. Please verify any information you receive from RDSA with other sources and with your licensed health care provider. Decisions regarding medical care should be made with your healthcare provider. Consumers should never disregard or delay seeking medical advice due to the content of this website. The RDSA executive and medical boards, volunteers and moderators do not assume, and hereby disclaims, any and all liability to any person or entity for any claims, damages, liability or other loss including, without limitation, any liability for injury or other damage resulting from any use of, or reliance on, this service or from the posting of any content or material by any third party.

Select an item (R)

Review of Medical Aid Correspondance - R350

Engage in dispute with Medical Aid - R850

Ex-Gratia Application - R2500

Preparation and participation in Dispute Hearing at Medical Aid - R3000

Complaint with Council for Medical Schemes - R3500

Thank you for you registering for our counselling service. You will receive an email shortly with further instructions on how to book your session.

registration

case

management

for a better tomorrow