Diaspora Medical Aid Plan Application Form – QuickMed Connections

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Diaspora Medical Aid Plan Application Form

We support Zimbabweans living abroad in ensuring their families back home have access to necessary healthcare services, regardless of their geographical location. COMPLETE THE FORM TO JOIN TODAY

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PART 1 -PERSONAL DETAILS

Details of the Person Responsible for paying the Account

Name of Sponsor/Principal *

Address in Country of Residence *

Contact Tel: *

(Please provide at least one telephone no so we can call you)

Email *

No of Dependents to be paid for:

(How many dependents do you wish to to pay medical aid for eg 1,2,3,4,5,6)

Medical Aid Package applied for:

GENCORE
GENCARE
GENLINK

What is the Source of your Funds? *

Salary/Wages
Savings/Investments
State Benefits
Pension
Business Income
Other

Please choose at least one of the sources of funds which you will be using to pay for the medical aid

Please Specify the 'Other' Source of Funds

PART 2- BENEFICIARY DETAILS

Beneficiary 1 Name: *

Name of Medical Aid Cover Chosen

GENCORE
GENCARE
GENLINK

Upload Beneficiarys’ ID Document

Click or drag a file to this area to upload.

Please attach the beneficiary’s ID Document eg Passport,ID or birth certificate

Beneficiary 2 Name:

Name of Medical Aid Cover Chosen

GENCORE
GENCARE
GENLINK

Upload Beneficiarys’ ID Document

Click or drag a file to this area to upload.

Please attach the beneficiary’s ID Document eg Passport,ID or birth certificate

Beneficiary 3 Name:

Name of Medical Aid Cover Chosen

GENCORE
GENCARE
GENLINK

Upload Beneficiarys’ ID Document

Click or drag a file to this area to upload.

Please attach the beneficiary’s ID Document eg Passport,ID or birth certificate

Beneficiary 4 Name:

Name of Medical Aid Cover Chosen

GENCORE
GENCARE
GENLINK

Upload Beneficiarys’ ID Document

Click or drag a file to this area to upload.

Please attach the beneficiary’s ID Document eg Passport,ID or birth certificate

Beneficiary 5 Name:

Name of Medical Aid Cover Chosen

GENCORE
GENCARE
GENLINK

Upload Beneficiarys’ ID Document

Click or drag a file to this area to upload.

Please attach the beneficiary’s ID Document eg Passport,ID or birth certificate

Beneficiary 6 Name:

Name of Medical Aid Cover Chosen

GENCORE
GENCARE
GENLINK

Upload Beneficiarys’ ID Document

Click or drag a file to this area to upload.

Please attach the beneficiary’s ID Document eg Passport,ID or birth certificate

PART 3 – CONTACT DETAILS OF PERSON IN ZIMBABWE

Please provide the contact details of the person who will be receiving all correspondence in Zimbabwe

Name of the Contact Person In Zimbabwe: *

Residential Address

Contact Telephone *

PART 4 – DETAILS OF GENERAL PRACTITIONER IN ZIMBABWE

Please provide the details of your dependents (Beneficiaries) General Practitioner (Doctors they usually go to ) in Zimbabwe ( if applicable)

1 - Name of the General Practitioner (Doctor)

Name of Surgery

Street Address of Surgery

Contact Telephone of Surgery

2 - Name of the General Practitioner (Doctor)

Name of Surgery

Street Address of Surgery

Contact Telephone of Surgery

3 - Name of the General Practitioner (Doctor)

Name of Surgery

Street Address of Surgery

Contact Telephone of Surgery

PART 5 – MEDICAL HISTORY

Medical details: Please enter the medical history of you and your dependants below. Failure to disclose medical conditions could limit your benefits, exclude you from receiving some benefits or result in termination of your membership.

1. Chronic illnesses (e.g. raised cholesterol, heart problems, diabetes, high or low blood pressure, asthma, depression and thyroid disorder) - Patient/s Name(s):

Condition:

Date of last treatment

2. Gastro-intestinal disorders (e.g. ulcers, stomach disorder, Crohn’s disease and ulcerative colitis) - Patient/s:

Condition:

Date of last treatment

3. Muscle, Bone, Skin or Nerve disorders (e.g. back and neck-related conditions, arthritis, multiple sclerosis, epilepsy, knee or hip ailments and psoriasis, eczema) - Patient/s:

Condition:

Date of last treatment

4. Urinary and reproductive disorders (e.g. kidney stones, prostate disorders, , endometriosis, ovarian cysts and menstrual disorders) - Patient/s:

Condition:

Date of last treatment

5. Ear, nose or throat disorders (e.g. glaucoma, cataracts, visual disorders, deafness and dental complications) - Patient/s:

Condition:

Date of last treatment

6. Blood diseases or cancer (e.g. cervical/ breast cancer, lymphomas, thalassemia, leukaemia) - Patient/s:

Condition:

Date of last treatment

7. Are you or any of your dependents pregnant? (If yes, provide details) - Patient/s:

Condition:

Date of last treatment

8. Have you or any of your dependents had surgery in the past, or are you planning to have surgery in the next 72 months?

Yes
No

9. ( If yes please provide details)

10. Are there any other conditions not listed above, for which medical advice, care or treatment has been recommended or received:

PART 6 - CONFIDENTIALITY CLAUSE

QuickMed Connections certifies that all the information submitted herein will remain confidential and intended solely for use of its diaspora medical cover scheme membership onboarding

PART 7 -DECLARATION

I declare that the information given herein was submitted willfully and is correct to the best of my knowledge. I agree that should my application be accepted by the Fund, l will abide by the rules, benefits and regulations set out by Generation Health Fund, details of which are available on request. Agreeing below signifies the basis of contract between Generation Health and myself.

Declaration *

I declare the above is true

Declaration Of Contract Agreement (Sign below)