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Patient Onboarding Form
Log An Authorization Dispute
Patient's First Name
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Patient’s diagnosis
Indication
Prescribed treatment
Doctor’s First Name
Doctor’s Last Name
Doctor’s Specialty
Doctor’s Email Address
Doctor’s Contact Number
Doctor's Practice Name
Doctor’s Practice Number
Help Needed
Drafting a letter of motivation
Medical Scheme authorization submission
Escalation of declined treatment
Application to patient assistance programme
Please upload Supporting documents
Upload File
Supporting documents
A copy of the motivation letter submitted to your Medical Scheme by your treating doctor.
Upload File
A copy of the treatment plan submitted to your Medical Scheme by your treating doctor.
Upload File
A copy of the decline letter or authorization letter sent by the Medical Scheme detailing the reason for the decline.
Upload File
Please upload any other documentation pertaining to your case
File Upload
I have read and agree to the
Terms and Conditions
Are you accessing a Patient Support Program?
Yes
No
Costs
Review of Medical Aid Correspondence - R450
Engage in dispute with Medical Scheme - R950
Ex-Gratia application with Medical Scheme - R2500
Preparation and Participation in Dispute Hearing with Medical Scheme - R3000
Council for Medical Schemes Complaint (Preparation and Submission) - R3500
Submit
