2019 Tel: 0860 787 372 Fax: 0860 288 363 Selfmed Medical Scheme P.O Box 5543 Tygervalley 7536
SELFMED OPTION CHANGE FORM
Reg. No: 1446
Only to be completed if you wish to change your option: Deadline for option change is 14 December 2018) Membership number: _______________________________________________________________________ “I, _______________________________________________________________ (full name) hereby request to change my option, as indicated here, with effect from 1 January 2019.” Please indicate, by means of an X in the appropriate block below, your choice of option:
MEDXXI
SELFSURE
MED ELITE
SELFMED 80%
from 1/1/2019 Principal Member
R 2,051
R 3,175
R 5,768
R 7,920
Adult Dependant
R 2,040
R 3,170
R 5,191
R 7,128
Minor Dependant
R 820
R 794
R 1,154
R 1,584
Mark here (X)
Declaration “I understand that the relationship between me (and any of my dependants) and the Scheme is controlled by the rules of the Scheme. I undertake to familiarise myself (and any of my dependants) with the rules of the Scheme, as well as the changes that are made to the rules from time to time and to abide by these rules.”
Signature
Date
Please return your completed option form to Selfmed Medical Scheme,
[email protected], PO Box 5543, Tygervalley, 7536 or fax it to 0860 288 363
