Immunoglobulin Therapy Funding Query

Patient Details

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date of Birth

Year

Month

Day

ID Number

Are you a Member of the following: (Select All that apply)

Rare Diseases South Africa

PiNSA

None

Medical Aid details

Medical Aid

Medical Aid Number

Plan

Main Member Full Name

Main Member ID Number

Doctors Details

Doctors Name

Doctors Email address

Doctors Contact Number

Clinical Details

Diagnosis

ICD Code Used

Current Medication

Overview of current funding query

Supporting Documentation

Please note the more information that is supplied to us in this query, the easier it is for RDSA to review. The below listed documents are the minimum requirements we will need to assist.

Latest Membership Certificate for your medical aid

Clinical Motivations written by your Doctor

Claims statements from your Medical Aid showing the short payments / declines / co-payments

Medical Scheme Correspondance (ie - decline / approval letters / email correspondance)

Supporting correspondence of adverse events, and measures taken to address them

Scripts (for current and intended treatment)

Any other relevant information you think we may need

I hereby acknowledge that my personal information, which includes information concerning my medical history, treatments and procedures performed on me or used by me, as the case may be, together with any related prrivate information and personal particulars, are being provided to RDSA, in order for them to provide patient support services to me.

I hereby authorise RDSA to collate and submit documentation on my behalf to the relevant parties, including but not liited to, my Medical Scheme and Council for Medical Schemes if necessary, and to act on my behalf in the dispute process.

I have further read, understood, and accept RDSA's privacy policy, as well as the terms and conditions of RDSA's patient services, and confirm that my consent in this respect has been provided out of my own free will.

Applicant's Signature

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