Bankmed Chronic Medication Programme Application Form
This form is essential for members of Bankmed who need to enroll in the Chronic Medication Programme. It includes personal details, healthcare provider information, and necessary clinical examinations. Ensure to complete all sections accurately for expedited processing.
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How do I fill this out?
To fill out this application form, carefully read each section and provide accurate information as requested. Ensure to double-check your details for any errors before submission. Reach out to your healthcare provider if you're unsure how to fill out any part of the form.

How to fill out the Bankmed Chronic Medication Programme Application Form?
1
Provide your personal and patient details in Section A.
2
Complete the healthcare professional's details and consent in Section B.
3
Fill out the clinical examination section as per instructions in Section C.
4
Provide the required clinical information and test results in Sections D.
5
Submit the completed form via email or fax as instructed.
Who needs the Bankmed Chronic Medication Programme Application Form?
1
Bankmed members seeking chronic medication benefits.
2
Healthcare professionals recommending chronic medication for their patients.
3
Individuals managing chronic health conditions requiring medication.
4
Family members completing the application on behalf of a patient.
5
Pharmacists needing to verify patient eligibility for medication plans.
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What are the instructions for submitting this form?
To submit your application form, please complete all sections carefully and ensure your details are accurate. Email the completed form to chronic@bankmed.co.za or fax it to 011 770 6247. Alternatively, you may contact 0800 BANKMED (0800 226 5633) for further assistance and submissions.
What are the important dates for this form in 2024 and 2025?
The important date for this form is its expiration on 31/03/2025. Ensure to submit the form before this date to remain eligible for the services. Regular updates and details are available on the Bankmed website.

What is the purpose of this form?
The purpose of this form is to enroll eligible members of the Bankmed Medical Scheme into the Chronic Medication Programme. This programme supports members by providing necessary medication management for chronic health conditions. Filling out this form ensures that patients receive the benefits they are entitled to under their medical scheme.

Tell me about this form and its components and fields line-by-line.

- 1. Member details: Includes plan type, membership number, title, birth date, ID number, name, and contact information.
- 2. Patient details: Gathers details about the patient, including their name, birth date, ID number, and contact information.
- 3. Healthcare Professional's details and consent: Captures the healthcare provider's name, practice number, and consent regarding the patient's treatment.
- 4. Clinical examination: Documents relevant clinical information regarding the patient's health status.
- 5. Clinical Information: Collects diagnosis details and relevant test results.
What happens if I fail to submit this form?
Failing to submit this form will result in the inability to process your application for the Chronic Medication Programme. Without valid submission, you may miss out on essential medication support services. It is crucial to complete and submit this form accurately and on time.
- Delayed processing: No consideration will be given to medication requirements without proper enrollment.
- Loss of benefits: Eligibility for the Chronic Medication Programme will be compromised.
- Increased health risks: Patients may face health risks without proper medication management.
How do I know when to use this form?

- 1. New enrollment: For members enrolling for the first time in the Chronic Medication Programme.
- 2. Medication updates: For existing members updating their medication needs.
- 3. Healthcare provider requests: When healthcare providers require documentation for patient prescriptions.
- 4. Family member enrollment: For family members who are completing the form on behalf of the patient.
- 5. Patient assessments: For healthcare assessments related to chronic conditions.
Frequently Asked Questions
What is the purpose of this form?
This form is used for enrolling in the Chronic Medication Programme offered by Bankmed.
How do I submit this form?
You can submit the form via email or fax as provided in the instructions.
What details are needed for submission?
You need to provide personal information, healthcare provider details, and clinical examination results.
Can I edit this PDF?
Yes, you can easily edit this PDF using PrintFriendly's PDF editor.
How do I sign the PDF?
Click on the 'Sign' option in PrintFriendly and follow the prompts.
What if I make a mistake on the form?
You can edit the form to correct any mistakes before submission.
What do I do if I have questions while filling it out?
Consult your healthcare provider for assistance with filling out the form.
Is there a deadline for submitting this form?
Yes, this form expires on 31/03/2025.
Are there updated forms available?
Yes, the most current forms can be found on the Bankmed website.
Who should fill out this form?
Members of Bankmed who need to enroll in the Chronic Medication Programme should complete this form.
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