Join Now Gap - Total Risk Administrators

SECTION 1: PERSONAL DETAILS

Medical Scheme*

Option*

Title*

First Names* (in full)

Date of Birth*

Contact Numbers*

Postal Address* (include postal code)

Medical Aid Number*

Gap Policy Number*

Initials*

Surname*

ID Number*

Email Address*

Comments

SECTION 2: CLAIM DETAILS

Beneficiary Name*

Beneficiary Name

Treatment Date* (yyyy/mm/dd)

Treatment Date (yyyy/mm/dd)

Provider Name & Practice Number*

Provider Name & Practice Number

Amount Claimed*

Amount Claimed

Total Amount Claimed

SECTION 3: REQUIRED DOCUMENTATION

It is very important that the medical aid statement reflecting the claims submitted, the hospital account and the doctor's statements are provided with this claim! If these documents are not attached it will be considered an invalid claim.

The following documentation is required BEFORE a claim can be processed. Please use the tick boxes to ensure that you have included the required documentation:

1. First 2 pages of Hospital Account or Pre-Authorisation Letter

I confirm that the first 2 pages of the Hospital Account or Pre-Authorisation Letter is attached.

2. Medical Aid Statement

I confirm that the Medical Aid Statement is attached.

3. Doctor / Service Provider Statement

I confirm that the Doctor / Service Provider Statement* is attached.

Upload Additional File 4

Upload Additional File 5

Upload Additional File 6

SECTION 4: POLICYHOLDER'S BANKING DETAILS - FOR CLAIMS REFUND PROCESS

Bank*

Account Number*

Account Type*

Branch*

Branch Code*

Other

As per the terms and conditions of this policy all the required information must be submitted to TRA within 3 months of the date of medical aid processing the claim after which the claim will be considered "stale". Refunds are generally made directly into the policyholder's bank account.

I declare that the aforegoing details are, to the best of my knowledge true, correct and complete: