Onboarding Sign Up - makotihealth.co.za

Welcome to Makoti Online Application

Kindly upload the following documents relevant to you (.pdf, .docx, .png, .jpeg, .jpg):

1. ID copy for the main member.

2. Certificate of membership from previous medical aid/s for all beneficiaries.

3. Proof of banking details (confirmation letter/not older than 3 months' bank statement).

4. A marriage certificate: should you not be married in court, an affidavit is required explaining the type of marriage and period of marriage.

5. Child (under 21): birth certificate/s.

6. Child dependant surname differs from main member (under 21): birth certificate and an affidavit explaining why the dependant surname differs.

7. Child dependant (over 21): birth certificate/ID copy; student letter confirmation from a certified institution for the current year and to be supplied yearly thereafter; affidavit confirming financial dependency upon the main member; and residence of the dependant.

8. Foster/adopted children: birth certificate/ID copy; foster documentation/adoption documentation.

9. Disabled child dependant: Birth certificate/ID copy; medical report.

10. Banking details and proof of banking details should a third party be responsible for paying contributions: fully completed 3rd party consent form.

I have all the listed documents ready in digital format. *
Applicant's Details

Please choose your plan *

Membership Commencement Date *

Date of Employment

First Name *

Please enter your name as registered on the ID.

Surname *

Please enter your surname as registered on the ID.

Date of Birth *

Occupation

Your current job title.

Identity Number Passport Number *

Employee Number

Please ensure your employee number is 6 digits long.

Income Tax Number

Please ensure your tax number is 10 digits long.

Basic Monthly Salary (R)

Net salary.

Race *

Marital Status *

Gender *

Email *

Email must meet standard format [email protected]

000-000-0000

Cellphone *

Home Telephone

Work Telephone

Physical Address *

Province *

Postal Code*

Postal Address *Same as Residential Address

Province *

Postal Code*
Would you like to add dependants?

How many dependants would you like to add? *

Race

Gender *

Name *

Please enter the dependant's name as registered on the ID.

Surname *

Please enter the dependant's surname as registered on the ID.

Living-In *

Income Per Month *

Monthly income after tax.

Identity Number Passport Number *

Relationship to member *

Race *

Gender *

Name *

Please enter the dependant's name as registered on the ID.

Surname *

Please enter the dependant's surname as registered on the ID.

Living-In *

Income Per Month *

Monthly income after tax.

Identity Number Passport Number *

Relationship to member *

Race *

Gender *

Name *

Please enter the dependant's name as registered on the ID.

Surname *

Please enter the dependant's surname as registered on the ID.

Living-In *

Income Per Month *

Monthly income after tax.

Identity Number Passport Number *

Relationship to member *

Race *

Gender *

Name *

Please enter the dependant's name as registered on the ID.

Surname *

Please enter the dependant's surname as registered on the ID.

Living-In *

Income Per Month *

Monthly income after tax.

Identity Number Passport Number *

Relationship to member *

Race *

Gender *

Name *

Please enter the dependant's name as registered on the ID.

Surname *

Please enter the dependant's surname as registered on the ID.

Living-In *

Income Per Month *

Monthly income after tax.

Identity Number * Passport Number

Relationship to member *
Previous Membership

Have you been a member of a medical scheme before? Yes No *

Name of Previous Medical Scheme *

The last scheme you were a member of.

Your Previous Membership Number *

Membership Number on Your Medical Aid Card

Date Joined *

Date of Termination *

Upload Previous Medical Scheme Document Here *
Chosen Doctor Details (General practitioner)

Name of Doctor of Choice *

Doctor you usually visit.

Doctor's Contact Number *

000-000-0000

Doctor's Email Address *

Email must meet standard format [email protected]

Doctor's Practice Number

Practice number must be 10 numbers.

Doctor's Physical Address *
Medical History

It is most important that the following questions be answered as thoroughly as possible. The answers to these questions will be treated as confidential. It is important to note that any medical condition, of which you are aware, not disclosed in this application, can be excluded from benefit. Please advise whether you or any of your dependants suffer from, or have suffered from, or received treatment/consultation for any of the following conditions. Please ensure that you tick and complete the appropriate fields.
Additional Medical History Information

Have you or any of your dependants ever received any form of physiotherapy, occupational therapy or chiropractic treatment?*

Are you or any of your dependants pregnant? If yes - how many weeks? Please give expected date of delivery.*

Have you or any of your dependants had any previous or pending claims for which any other party may be liable e.g. MVA (Motor Vehicle Accident) claims? If yes, please give details. *

Are you or any of your dependants expecting to undergo any medical treatment, e.g. hospitalisation, operation, specialised dentistry etc, within the next twelve months? *

Do you or any of your dependants have a chronic condition requiring ongoing medication? If yes, please give the name and dosage of all the medication you or any of your dependants are currently taking. *

Have you or any of your dependants ever received any medical attention of any nature, e.g., hospitalisation, operation, specialised dentistry etc, not mentioned above? *

Have you or any of your dependants ever appeared before a medical board in view of early retirement and declared medically unfit? *
Employer

Employer's Name

The company you currently work form.

Employer's Contact Number

000-000-0000

Date
Banking Details

Name *

The person to which the account belongs to.

Surname *

The person to which the account belongs to.

Account Number *

Bank Account Number.

Branch Code *

The name of the bank where you opened your account.

Name of Bank *

Branch Name *

The name of the bank where you opened your account.

Account Type *
Broker Details

Brokerage Name

The company the broker works for.

Broker's Name

As displayed on business business card/ web site.

Broker's Code

Code given to you by the broker.

Broker Cellphone Number

000-000-0000

Broker Office Telephone Number

000-000-0000
Broker Consultant

Broker Consultant Name

As displayed on business business card/ web site.

Broker Consultant Code

Broker consultant code must be 10 numbers

Date of Consultation
Document Uploads

Kindly upload the following documents relevant to you (.pdf, .docx, .png, .jpeg, .jpg):

1. ID copy for the main member.

2. Certificate of membership from previous medical aid/s for all beneficiaries.

3. Proof of banking details (confirmation letter/not older than 3 months' bank statement).

4. A marriage certificate: should you not be married in court, an affidavit is required explaining the type of marriage and period of marriage.

5. Child (under 21): birth certificate/s.

6. Child dependant surname differs from main member (under 21): birth certificate and an affidavit explaining why the dependant surname differs.

7. Child dependant (over 21): birth certificate/ID copy; student letter confirmation from a certified institution for the current year and to be supplied yearly thereafter; affidavit confirming financial dependency upon the main member; and residence of the dependant.

8. Foster/adopted children: birth certificate/ID copy; foster documentation/adoption documentation.

9. Disabled child dependant: Birth certificate/ID copy; medical report.

10. Banking details and proof of banking details should a third party be responsible for paying contributions: fully completed 3rd party consent form.

Upload all the listed for documents here *

Upload all the listed for documents here *

Upload all the listed for documents here *

Upload all the listed for documents here *

Upload all the listed for documents here *

Upload all the listed for documents here *
The following will apply in respect of exchange of confidential information and medically confidential information concerning members and their dependants:

1. For the purpose of considering applications for membership, as well as any claim for benefits, the Makoti Medical Scheme and any medical personnel authorised by Makoti Medical Scheme has the right to obtain any medically relevant information which it may deem necessary from any medical practitioner or institution or nominee that possesses such information, and that party may disclose such information to the Makoti Medical Scheme and any party duly authorised by the Makoti Medical Scheme.

2. The Makoti Medical Scheme and any medical personnel duly authorised by Makoti Medical Scheme may request and acquire from service providers any relevant information that may be required for the fulfilment of any of its obligations. The Makoti Medical Scheme and any party duly authorised by the Makoti Medical Scheme may keep such information in their databases and use it for statistical purposes.

3. The information may be requested and supplied at any time, including after the death of the member or dependants, and will include accounts from service providers, indicating diagnoses, and medical or clinical reports when indicated. Such information will, however, be treated as confidential at all times by the party to whom its supplied.

4. By agreeing to sign the application form(s) the applicant/member and dependants thereby waives his/her right to privacy to the extent implied by the above clauses 1, 2 and 3.

I agree. *
I DECLARE THAT I HAVE DISCLOSED ALL PARTICULARS RELEVANT TO THIS APPLICATION, AND THAT I AM AWARE THAT ANY FALSE STATEMENT WILL RENDER MY MEMBERSHIP NULL AND VOID.