Methealth | NMC Membership

APPLICATION FOR NMC MEMBERSHIP

Form Version: 2023 | Health Questions: 23

Please have the following documentation ready:
* ID / Passport of Principal Member (Required)
* ID / Passport of Spouse (if applicable)
* Marriage Certificate (if applicable)
* ID / Passport / Birth Certificates of other dependants (if applicable)
* Student Letter for dependants that are studying (if applicable)
* Membership Certificate if you are a continuous member of another medical aid scheme for the past 2 years
* Declaration for common law husbands / wives, cohabitant partners
* Legally adopted children - please attach necessary documents

PLEASE COMPLETE ALL THE APPLICABLE SECTIONS IN FULL

A. BENEFIT OPTION

STATUS OF APPLICANT
EXISTING MEMBER NUMBER
BENEFIT OPTION
Required date of Membership
Application Type
Group Number (Required)
Group Name
Group Email

B. PARTICULARS OF PRINCIPAL MEMBER

TITLE:
SURNAME:
FIRST NAMES:
POSTAL ADDRESS:
POST OFFICE: CITY / TOWN:
COUNTRY:
POSTAL CODE:
RESIDENTIAL ADDRESS:
TOWN / CITY:
SUBURB:
COUNTRY:
HOME TEL. CODE & NO.:
WORK TEL. CODE & NO.:
CELL NO.:	+264
DATE OF BIRTH:
MARITAL STATUS:
GENDER:
ARE YOU A PENSIONER:
EMAIL ADDRESS (PRINCIPAL MEMBER):
EMAIL ADDRESS (SPOUSE):
ID TYPE:
ID/PASSPORT NO.:
OCCUPATION (PRINCIPAL MEMBER):
GROSS MONTHLY INCOME (MEMBER) N$ (Compulsory for Opal):
APPLICATION SUBMITTED BY:
SUBMITTER's EMAIL: (The confirmation email will be forwarded to this email address)

C. EMPLOYER DETAILS

EMPLOYER NAME:
EMPLOYER POSTAL ADDRESS:
EMPLOYER TOWN:
EMPLOYER COUNTRY:
TEL. CODE & NO.:
FAX. CODE & NO.:

D. PARTICULARS OF PREVIOUS MEDICAL COVER

Were / Are you a member/dependant of a Namibian registered medical aid fund uninterruptedly for the past two years? If 'yes', please attach a certificate(s) of membership from your current / previous medical aid fund (a membership card is not sufficient).

NAME OF PRESENT MEDICAL AID FUND:		MEMBERSHIP NUMBER:
PERIOD OF MEMBERSHIP: (FROM)		TO:

NAME OF PREVIOUS MEDICAL AID FUND:		MEMBERSHIP NUMBER:
PERIOD OF MEMBERSHIP: (FROM)		TO:

E. PARTICULARS OF DEPENDANTS

Husband, wife and children under 21 years, who are unmarried and not in full employment. Children up to 25 years may be included if they are full-time students at a recognised educational institution*. Attach proof of registration. For more than five (5) Children, please attach a list. (If legally adopted, please attach necessary documents). If surnames differ from that of Principal Member, please provide documentary proof of relationship.
*Recognised educational institution as per the rules of Namibia Medical Care.

	Dependants	Full First Names	Surname	Relationship	Date of Birth	ID Type	Nationality	ID/Passport No.
	Dep. 1
	Dep. 2
	Dep. 3
	Dep. 4
	Dep. 5
	Dep. 6

Please upload the following documents (Compulsory)

Dep. Type	Dep. Name	File Required	Upload

F. STATE OF HEALTH
TO BE SUPPLIED BY MEMBER/APPLICANT (COMPULSORY)

Please give the name and address of your general practitioner, dentist, as well as any specialist you may have consulted recently.

Dentist:		Doctor:		Specialist:
Tel No.:		Tel No.:		Tel No.:

Have you, your spouse or any dependants ever experienced any of the following:

1. Any disorder of the heart (e.g. angina, heart attack, heart murmur, rheumatic fever, coronary artery disease, chest pain, shortness of breath, palpitations, congenital disorders, etc.)?
2. High blood pressure or disease of the blood vessels or circulatory disorder (e.g. high cholesterol, stroke, thrombosis, cramps in the calves with exercise or walking etc.)?
3. Any respiratory or lung disease/disorder (e.g. asthma, bronchitis, tuberculosis, persistent cough)?
4. Any disorder of the digestive system, gall bladder, pancreas or liver (e.g. hiatus hernia, recurrent indigestion, suspected gastric or duodenal ulcer, rectal bleeding, piles or jaundice or have you ever had a gastroscopy)?
5. Disease or disorder of the kidney, bladder or reproductive organs (e.g. protein in the urine, kidney stones, nephritis, prostatitis, cystitis or sexually transmitted disease)?
6. Diabetes, thyroid or other glandular or blood disorders (e.g. anaemia or bleeding disorders, leukaemia, haemophilia)?
7. Eye, ear, nose or throat disorder (e.g. defective vision, hearing loss, ear discharge, recurrent tonsillitis, hoarseness, retinitis pigmentosa, glaucoma)?
8. Nervous or mental complaint (e.g. epilepsy, blackout, paralysis, anxiety state or depression, chronic headaches, fits, fainting, multiplev sclerosis, brain impairment)?
9. Disorder or disease of the skin eruption, (e.g. porphyria, psoriasis, dermatitis, muscles, bones, joints, limbs or spine, e.g. rheumatism, arthritis, gout, slipped disc or other back condition)?
10. Any tropical disease (e.g. bilharzia, malaria, brucellosis)?
11. Cancer, a growth or tumor of any kind?
12. Any other illness, disorder or operation, disability or accident, (INCLUDING MOTOR VEHICLE ACCIDENTS) which required medical, radiological, surgical, pathological investigations, or have you ever been hospitalised?
13. Do you or any of your dependants have any physical (including dental), abnormality, deformity, handicap or defect, whether congenital or as a result of an accident, disease or some other cause? For dental system (poor closure of jaws, implants, orthodontic, periodontic or maxillofacial surgery).
14. Are you or your dependants currently undergoing or expecting to undergo any medical, dental, or surgical treatment?
15. Are you or any of your dependants pregnant? If yes, state expected date of delivery.
15.1. Did you or any of your immediate family e.g. mother, dependants, sister experience any complications with previous pregnancies?
15.2. Are there any complications or health problems detected in you or your immediate family ‘s current pregnancy or that of the unborn baby?
16. Does any member of your (or your spouse’s) immediate family e.g. parents, brothers or sisters suffer from diabetes, heart disease, high blood pressure, raised cholesterol, mental disease, porphyria or any other disease?
17. Did you experience any health problems or show signs and symptoms of health problems in the last 3-months before applying for membership?
18. Has your weight or the weight of your spouse/dependant changed more that 5kg in the last 12 months?
19. Are you or your dependants smokers?
20. Are there any addictions we should be aware of?

21. Height & weight (Principal Member)	Height	Weight
Height & weight (Dep. 1)	Height	Weight
Height & weight (Dep. 2)	Height	Weight
Height & weight (Dep. 3)	Height	Weight
Height & weight (Dep. 4)	Height	Weight
Height & weight (Dep. 5)	Height	Weight
Height & weight (Dep. 6)	Height	Weight

G. CHRONIC MEDICATION
Do you or any of your dependants use chronic medication?

H. YOUR BANKING ACCOUNT DETAILS

(Required for refunding any amounts due to the member directly into account)

ACCOUNT HOLDER TITLE:
ACCOUNT HOLDER NAME:
ACCOUNT HOLDER SURNAME:
ACCOUNT NO.: (Numeric Only)
BANK NAME:
BRANCH CODE: (6 numeric characters)
BRANCH NAME:
TYPE OF ACCOUNT:

File Required	Upload
Bank Confirmation Letter

Please note:
* a bank confirmation letter is required; and
* No post office savings accounts are allowed

I. DEBIT ORDER
Will you be paying by debit order?

Tutorial: Application for Membership as Individual (PDF)
Tutorial: Application for Membership as employee of an Employer Group (PDF)

Need help?

Question No.:	Beneficiary (Name of Person)	Illness or Condition	Date and duration of the illness or condition	Date and nature of treatment received medical or surgical: result of treatment	Name of doctor hospital or institution:	Treatment recommended: likely date and duration of treatment

Beneficiary	Diagnosis	Medication Prescribed	Strength (e.g. 5mg)	Dosage (e.g. 2 tablets daily)	From	To