Your quick guide to completing

this application form

Who we are

The Government Employees Medical Scheme (GEMS) [Registration Number 1598] is a restricted medical scheme registered in terms of the
Medical Schemes Act 131 of 1998 (the Act), to provide qualifying public service employees and their families with equitable access to affordable
and comprehensive healthcare benefits. GEMS offers six excellent healthcare benefit options: Tanzanite One, Beryl, Ruby, Emerald Value,
Emerald and Onyx.

For more information on how to join GEMS, please visit www.gems.gov.za, or call 0860 00 4367, or SMS “please call me” to 083 450 4367 and
an agent will call you.

Compulsory documentation required from main member

For member: For each dependant: For Pensioner:

• Clear copy of Green ID Book/ Smart ID with both • Clear copy of Green ID Book/ • Clear copy of Green ID Book/ Smart ID
sides / SA Passport Smart ID with both sides/ Birth with both sides/ SA Passport
• Latest salary advice or letter of appointment (not Certificate/ SA Passport • Z583 (stamped by Commissioner of Oaths)
older than 3 months) • Previous medical aid certificate • Previous medical aid certificate with
• Bank statement with stamp (not older than 3 months) with resignation date (if applicable) resignation date (if applicable)
• Previous medical aid certificate with resignation date
(if applicable)

Additional documentation required for each dependant

Description of dependant Documentation required

Spouse • If legally married, a copy of marriage certificate is required

• If in a customary marriage, a declaration* from the member confirming obligation towards
his/ her spouse is required

Ex-spouse • Evidence of legal obligation to provide medical support per divorce settlement or court, e.g.
the Divorce Order.

Life Partner • A declaration* confirming that the dependant is the member’s life partner.

Child under the age of 21 • A declaration* confirming obligation towards the child and reason for difference in surname if
the child’s surname differs from the main member.
• Legal documentation if child is adopted.

Child of 21 and older • For students:

- Proof of registration at a recognised tertiary institution; and
- A declaration* confirming factual dependency on the main member.
• For mental or physical disability:
- Proof of disability from a medical practitioner (a medical assessment report completed by
a medical practitioner); and
- A declaration* confirming factual dependency on the main member, and that the child is
not in a state institution.
• If the child is not a student nor disabled:
- A declaration* confirming factual dependency on the main member.

Extended family • A declaration* confirming factual dependency of any such dependants.

(Parents, step parents, parents-in-law,
step-parents-in-law, grandparents or
grandparents-in-law)

Declaration* - A declaration may be a letter, email, or telephone call from the main member.
Factual dependence - A factual dependant depends on the main member for family care and support.

Take Note:
• Adult dependant rates are payable for all eligible dependants who are 21 years of age or older.
• Child rates are payable for disabled dependants, and dependants under 28 years who are enrolled for any course(s) or undergoing supervised
practical training.
• Your adult dependant(s) will be subject to at least an annual eligibility review. You must provide proof of dependency of all dependants over the
age of 21 every year. Proof of eligibility may be required, for example proof of student registration.

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Submitting your completed form

Submit your completed form in any of the following ways:

Email: [email protected] • Fax: 0861 00 4367 • Post: GEMS at Private Bag X782, Cape Town 8000
Walk-in Centres: Drop it off at any of the following GEMS Walk-in Centres:

Eastern Cape • East London: Shop LG36, Lower Level, Gillwell • Mthatha: Savoy Complex, Unit 11 & 12A, Nelson
Shopping Centre, c/o Gillwell Road and Fleet Street Mandela Drive

Free State • Bloemfontein: Bloem Plaza, Shop 124, Charlotte • Welkom: Gold Fields Mall, Shop 51A, c/o Stateway &
Maxeke Street Buiten Street

Gauteng • Johannesburg: Traduna House, 118 Jorrisen Street, • Pretoria: Sancardia Building, Shop 51, First Floor, c/o
Ground Floor, c/o Jorrisen and Civic Boulevard Beatrix & Church Streets, Arcadia
(opposite Civic Centre), Braamfontein

KwaZulu-Natal • Durban: The Berea Centre, Shop G18, Entrance 1, • Pietermaritzburg: Deloitte House, Suite 3, Block A, 181
249 Berea Road, Berea Hoosen Haffejee Street (Berg Street)

Limpopo • Polokwane: Shop 1, 52 Market Street • Thohoyandou: Unit G3, Metropolitan Centre

Mpumalanga • Nelspruit: Shop No. 18, Nedbank Centre, 30 Brown • eMalahleni (Witbank): Safeways Crescent Centre,
Street, Nelspruit CBD Shop S67, c/o President & Swartbos Streets, Die Heuwel

Northern Cape • Kimberley: New Park Centre, Shop 14, Bultfontein • Upington: 61A Mark Street
Way & Lawson Street

North West • Klerksdorp: City Mall, Shop 101, c/o OR Tambo & • Mafikeng: Mmabatho Megacity Shopping Centre, Shop
President Street, Klerksdorp CBD 39, c/o Sekame & James Moraka Streets, Mmabatho

Western Cape • Worcester: Mountain Mill Shopping Centre, Shop 125 • Cape Town: Constitution House, 124 Adderley Street
A & B, Mountain Mill Drive

Use this checklist to ensure that you have completed all the relevant sections.
n Section 1: Main member employment details n Section 6: Medical history and general health information
n Section 2: Main member details n Section 7: Benefit option selection
n Section 3: Preferred method of communication and language preference n Section 8: Payment of contributions
n Section 4: Dependants you wish to register n Section 9: Your bank account details
n Section 5: Previous medical scheme details n Section 10: Terms and Conditions (your responsibilities)

Important to note
• If you have not heard from us within 7 days of submitting your application, please call us on 0860 00 4367 or
email us on [email protected]
• “Cooling off period”: GEMS allows new members to cancel their GEMS membership within 15 days after the start of membership,
provided no healthcare benefits have been claimed.
• Read the terms and conditions on page 10 carefully. They contain important provisions about this application and your GEMS
membership.
• As a GEMS member, you and your registered dependants will be bound by the Scheme Rules accessible on: www.gems.gov.za
• GEMS reserves the right to impose waiting periods as defined in the Scheme Rules.

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Membership Application Form

This is an application form for GEMS membership. Please complete all the sections in full.

Section 1: Main member employment details

Current employment

Persal, Employee or Pension number nnnnnnnnnnnnnnnnnnnnnnnnnnnnnn

Current employer’s name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Organisation code nnnnnnnnnn n Permanent Employee n Temporary Employee
Employment start date nnnnnnnn
D D MM Y Y Y Y Pensioner retirement date nnnnnnnn
D D MM Y Y Y Y
Income tax no. nnnnnnnnnnnnnnnnnn
Previous employment

(1) Previous employer’s name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn

Employment start date nnnnnnnn
D D M M Y Y Y Y Employment end date nnnnnnnn
D D MM Y Y Y Y
Reason for leaving

(2) Previous employer’s name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn

Employment start date nnnnnnnn
D D M M Y Y Y Y Employment end date nnnnnnnn
D D MM Y Y Y Y
Reason for leaving

Section 2: Main member details

Names nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Surname nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
ID/Passport no. nnnnnnnnnnnnn Date of birth nnnnnnnn
D D MM Y Y Y Y
Country of origin nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Country in which passport was issued nnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Visa number nnnnnnnn Race nnnnnnnn (for statistical purposes only)

Gender Male Female Marital status Single Married Divorced Widowed Co-habiting

Residential address Unit/Apartment no. nnnn nnnnnnnnnnnn

Complex/Building name

Street no. nnnnnn Street name nnnnnnnnnnnnnnnnnnnnnnnn

Suburb nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
City nnnnnnnnnnnnnnnnnnnnnnnnn Postal code nnnnn
Telephone (H) nnnnnnnnnn Telephone (W) nnnnnnnnnn
Mobile no. nnnnnnnnnn
Email address nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Postal address If postal address is the same as residential address - tick box n

n PO Box n Private Bag X Number (complete the number) nnnnnnnnnn

n Postnet Suite n Apartment Number (complete the number) nnnnnnnnnn
Suburb nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
City nnnnnnnnnnnnnnnnnnnnnnnnn Postal code nnnnn
In case of emergency please contact (name and relationship)

Telephone (H) nnnnnnnnnn Mobile no. nnnnnnnnnn

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Section 3: Preferred method of communication and language preference

Preferred method of communication n Post n Email

Please indicate in which language you prefer to receive your communication? Please note that if you do not choose any language,
your language preference will be registered as English.

n Afrikaans n English n Ndebele n Sepedi n Sesotho n SiSwati

n Setswana n Tshivenda n isiXhosa n Xitsonga n isiZulu

Section 4: Dependants you wish to register

(If you wish to add more dependants please include the additional dependants on a separate sheet of paper when submitting this application)

Dependant 1
Names nnnnnnnnnnnnnnnnnn Surname nnnnnnnnnnnnnnnnnn
Date of birth nnnnnnnn
D D MM Y Y Y Y ID/Passport no. nnnnnnnnnnnnn Gender Male Female

Race nnnnnnnn Country of origin nnnnnnnnnnnnnnnnnnn

(for statistical purposes only)

Country in which passport was issued nnnnnnnnnnnnnnnnnn Visa number nnnnnnnn

Email address nnnnnnnnnnnnnnnnnnnnnnnn Mobile no. nnnnnnnnnn
Relationship to main member nnnnnnnnnnnnnnnnn Income of dependent nnnnnn . nn
Is the dependant factually dependent on main member? n Yes n No Is the dependant n Student n Mentally/Physically disabled

Dependant type n Spouse n Ex-spouse n Partner n Child under the age of 21 n Child of 21 and older
n Extended family (Parents, step parents, parents-in-law, step-parents-in-law, grandparents or grandparents-in-law)
Extent of financial dependency on member

Dependant 2
Names nnnnnnnnnnnnnnnnnn Surname nnnnnnnnnnnnnnnnnn
Date of birth nnnnnnnn
D D MM Y Y Y Y ID/Passport no. nnnnnnnnnnnnn Gender Male Female

Race nnnnnnnn Country of origin nnnnnnnnnnnnnnnnnnn

(for statistical purposes only)

Country in which passport was issued nnnnnnnnnnnnnnnnnn Visa number nnnnnnnn

Email address nnnnnnnnnnnnnnnnnnnnnnnn Mobile no. nnnnnnnnnn
Relationship to main member nnnnnnnnnnnnnnnnn Income of dependent nnnnnn . nn
Is the dependant factually dependent on main member? n Yes n No Is the dependant n Student n Mentally/Physically disabled

Dependant type n Spouse n Ex-spouse n Partner n Child under the age of 21 n Child of 21 and older
n Extended family (Parents, step parents, parents-in-law, step-parents-in-law, grandparents or grandparents-in-law)
Extent of financial dependency on member

Dependant 3
Names nnnnnnnnnnnnnnnnnn Surname nnnnnnnnnnnnnnnnnn
Date of birth nnnnnnnn
D D MM Y Y Y Y ID/Passport no. nnnnnnnnnnnnn Gender Male Female

Race nnnnnnnn Country of origin nnnnnnnnnnnnnnnnnnn

(for statistical purposes only)

Country in which passport was issued nnnnnnnnnnnnnnnnnn Visa number nnnnnnnn

Email address nnnnnnnnnnnnnnnnnnnnnnnn Mobile no. nnnnnnnnnn
Relationship to main member nnnnnnnnnnnnnnnnn Income of dependent nnnnnn . nn
Is the dependant factually dependent on main member? n Yes n No Is the dependant n Student n Mentally/Physically disabled

Dependant type n Spouse n Ex-spouse n Partner n Child under the age of 21 n Child of 21 and older
n Extended family (Parents, step parents, parents-in-law, step-parents-in-law, grandparents or grandparents-in-law)
Extent of financial dependency on member

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Section 5: Previous medical scheme details

Have you ever been a main member or a dependant of GEMS? n Yes n No

If Yes, provide your previous membership number nnnnnnnnnnnnnnnnnnnn
Complete previous scheme details below:

Member/Dependant Scheme name Start date Is the dependant End date if Reason for leaving
Name still a member? already resigned

n Yes n No
n Yes n No
n Yes n No
n Yes n No
Please remember to attach your previous medical aid certificate for each dependent with resignation date (if applicable).

Section 6: Medical history and general health information

If you do not disclose pre-existing conditions, certain benefits could be limited and/or excluded. Failure to disclose any pre-exisiting medical
condition will result in a non-disclosure investigation.

HIV/AIDS

Although you do not have to disclose your HIV status on this form, you must contact our confidential HIV line in order to disclose on 0860
436 736 within seven working days of submitting your membership application to GEMS.

This information will be kept confidential.

Disclosure of medical history

Please answer the questions below by marking the relevant box with an X.
In the last 12 months, have you or any of your dependants (excluding newborns and/or newly-adopted children)
received or been recommended for any medical advice, diagnosis, treatment or care for any of the following conditions?

1. Do you or any of your dependants use chronic medicine? n Yes n No

2. Disorders or problems with the heart or cardiovascular system n Yes n No

Example: Heart murmur, high blood pressure, high cholesterol, shortness of breath, palpitations, chest pains, angina, heart attack and/or
any other cardiac or blood disorder.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

3. Respiratory or lung disorders n Yes n No

Example: Tuberculosis, asthma, persistent cough or other breathing problems, emphysema, coughing up blood, cystic fibrosis, sinusitis or
allergic rhinitis.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

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4. Gynaecological disorders n Yes n No
Example: Abnormal pap smear or mammogram, endometriosis, ovarian cysts, fibroids, infertility, disorders of the cervix, menstrual disorders
or any abnormality of pregnancy or confinement.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

5. Pregnant or suspecting pregnancy? n Yes n No

Patient name Treating doctor Last menstrual cycle date Delivery date

6. Disorders of the digestive system, stomach, gall bladder, pancreas or liver n Yes n No
Example: Gastric or duodenal ulcer, heartburn, hiatus, rectal bleeding, Crohn’s disease, ulcerative colitis, irritable bowel syndrome, hepatitis
cirrhosis, liver failure, or have you ever had gastroscopy or colonoscopy.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

7. Disease or disorders of the kidneys, bladder or reproductive organs n Yes n No

Example: Abnormal urine tests, kidney stones, nephritis, prostatitis, bladder infections or sexually transmitted diseases.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

8. Disorders of the nervous system or brain n Yes n No

Example: Epilepsy, stroke, multiple sclerosis, migraine, headaches, paralysis, Parkinson’s disease or have you or any of your dependants
been advised to have a MRI or CT scan.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

9. Mental disorders n Yes n No

Example: Depression, anxiety, panic attacks, schizophrenia, eating disorders, attention deficit hyperkinetic disorder (ADHD or post-traumatic
stress disorder).

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

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10. Ear, nose, throat or eye disorders n Yes n No
Example: Defective vision, cataracts, glaucoma, retinitis, disorders of the cornea, hearing loss, ear discharge, otitis media or allergies.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

11. Disorders or diseases of the skin, muscles, bones, joints, limbs or spine n Yes n No
Example: Any skin rash, arthritis, gout, fibromyalgia, any back/neck/hip/knee or other joint trouble,
multiple sclerosis, any joint problems or replacements, acne, eczema or psoriasis.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

12. Diabetes, sugar in urine, thyroid or other glandular or blood disorders n Yes n No
Example: Growth disorders, Cushing’s disease or Addison’s disease.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

13. Removal of cancer, growth or tumour including moles n Yes n No

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

14. On or anticipating any specialised dental/maxillofacial treatment n Yes n No

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

15. Any accident, including motor vehicle accidents n Yes n No

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

16. Any surgical procedures n Yes n No

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

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17. Awaiting or planning any surgical procedures or admission to any hospital in the next 12 months n Yes n No

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

18. Taking on-going medicine for any condition not listed above n Yes n No
Example: Homeophatic, over the counter.

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

19. Any other condition or symptom, not listed above, for which medical advice, diagnosis, care or treatment
has already been recommended or received, or could result in a medical claim within the next 12 months n Yes n No

Patient name Illness or Date first Date of last Treatment Name of treating Doctor’s contact
condition diagnosed occurrence recommended doctor details
(medicine, etc.)

Section 7: Benefit option selection

Please select only one benefit option from the list below and mark the applicable block with an X.

n Tanzanite One n Beryl n Ruby n Emerald Value n Emerald n Onyx

• If you have selected the Tanzanite One or Emerald Value option, you need to indicate a Network doctor for yourself and your dependant(s).
• You can access the Network doctors on www.gems.gov.za> Member > Providers
• If you and your dependant(s) will be using the same nominated GP - tick box n
• If you have ticked the above box, you only need to complete the main member GP nomination.
• A 30% co-payment will apply to claims where a GP has not been nominated in line with the Scheme Rules.

Member/ Doctor’s telephone

Name of GEMS beneficiary Name of GP Practice number
Dependant number
PRIMARY GP
Main member
SECONDARY GP
PRIMARY GP
Dependant 1
SECONDARY GP
PRIMARY GP
Dependant 2
SECONDARY GP
PRIMARY GP
Dependant 3
SECONDARY GP

* If you wish to add more dependants please include the additional dependants on a separate sheet of paper when submitting this application.

Please note: Your start date will always be on the 1st day of the next month, if all relevant and completed documentation is received. If
submission of your application form and last document are received after the Persal cut-off, you may be given the option to register either for the
1st of the following month with a double deduction, or the month thereafter with a single deduction. Please check your membership certificate to
see your start date and if any waiting periods apply.

For example, should the last document be received on 26 April and the Persal cut-off date is 25 April, you will be given the option of admission
to the Scheme either from 1 May or 1 June. In this instance, the 1 May admission will incur a double deduction in June (for contributions of both
May and June) due to the Persal cut-off, and the 1 June admission will incur a single deduction in June. Please note, the collection of premiums
are collected in arrears.

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Section 8: Payment of contributions

Persal employees
Monthly contributions are deducted automatically from the main member’s salary.

If you are paying your own contributions

Your membership will be activated upon your consent to pay 100% of your contribution via debit or cash until your subsidy has been confirmed
by the Government Employees Pension Fund (GEPF).

Please choose only one payment method n Debit order n Cash n EFT n Stop order
For debit order selected, please take note:
Acknowledgement and declaration
1. This will commence at the beginning of the month following the month of registration date and continue until this Authority and Mandate is
terminated by me giving notice in writing within 20 business working days.
2. In the event that the payment day falls on a Sunday, or a public holiday, the payment will automatically be deducted on the next business day.
3. I acknowledge that all payment instructions issued by you shall be treated by my above-mentioned Bank as if the instructions have been issued
by me personally.
4. I agree that although this Authority and Mandate may be cancelled by me, such cancellation will not cancel the Agreement. I shall not be entitled
to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you.
5. I acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in
the absence of such assignment of the Agreement this Authority and Mandate cannot be assigned to any third party.
6. I understand that the subsidy portion of my contribution will only be refunded to me upon receipt of my subsidy from National Treasury.
7. I understand that it is my responsibility to ensure that the full contribution is received by GEMS on the payment due date.

Account holder’s signature Date of signature nnnnnnnn

D D MM Y Y Y Y

Cash/ EFT/ Stop order payment of contributions

If you choose to pay in cash, please use the following banking details when depositing your contribution:
Bank: First National Bank (FNB) Account name: Government Employees Medical Scheme
Account no: 62094049593 Branch code: 204109 Reference: Your membership no.

If you do not provide your membership number as reference, we will not be able to allocate the payment correctly.

Section 9: Your bank account details

This section is compulsory and needs to be completed in full, as we cannot register you as a member of GEMS if we do not have your bank
account details. We require these details to pay any money that may be due to you, to collect your medical scheme contributions (if applicable)
or any money that you may owe GEMS.
Name of bank nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Name of account holder nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Bank account no. nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Branch name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Branch code nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Type of account n Current n Savings n Transmission
Debit order reference: GEMSGOVMED Your Membership no. (e.g. GEMSGOVMED123456789)
I understand that the estimated monthly contributions (which are dependent on the value of any subsidy received) that I will be expected to pay
if this application is accepted have also been explained to me prior to me making this application.
I hereby authorise you to issue and deliver payment instructions n Monthly n Annually for collection against my bank account.

Please remember to include required FICA Documents:

• Clear copy of Green ID Book/ Smart ID with both sides /SA Passport
• Bank Statement with stamp (not older than 3 months)
• Proof of address (not older than 3 months)

Account holder’s signature Date of signature nnnnnnnn

D D MM Y Y Y Y

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Section 10: Terms and conditions (your responsibilities)

Your application form will not be processed without your signature in this section.

Please read the terms and conditions below carefully. These contain acknowledgements of fact that may impact on your rights. These terms and conditions
shall be read together with the Rules of GEMS and the Act, and all these provisions shall be binding on you and your dependants. The Rules are available
on the GEMS website at www.gems.gov.za.
1. These terms and conditions shall be read together 11. If I am accepted as a member, I must, both now 17. You agree that the Scheme and its administrator
with the Registered GEMS Rules, which are and in future, give GEMS all such information may process you and your dependants’ personal
available on GEMS’ website, www.gems.gov.za, and evidence as it may require from time-to-time information for, inter alia, the following purposes:
or by calling 0860 00 4367. for purposes of my dependants and my 17.1. to assess and process this application for
2. I hereby apply for my dependants and I to join membership of GEMS. For this purpose, I membership;
GEMS and I confirm that I am duly authorised to authorise GEMS and/or its agents to obtain from 17.2. for the administration of your health plan;
apply on behalf of the persons listed as any person any information that they may require 17.3. for the provision of managed care services
dependants in this application form. concerning me or any of my dependants for any to you on your health plan;
3. I understand that if my dependants and I are purpose which directly relates to our medical 17.4. for the provision of relevant information to
accepted as members of GEMS, my answers on scheme membership or which is authorised in a contracted third party who requires this
this form and supporting information supplied will terms of the Act, the Rules or any other information in order to provide a
form the basis of our membership. I furthermore legislation. I direct that person to provide GEMS healthcare service to you on your health
confirm that should I fail to disclose any material and/or its agents with such information on plan;
information, my and my dependant’s membership request. 17.5. to profile and analyse risk;
may be cancelled or suspended. 12. I hereby authorise any medical doctor or other 17.6. to share your personal information with
4. I hereby declare that the dependant(s) listed on healthcare provider who has attended to me or external health specialists for them to
this application form is unable to support himself/ my dependants in the past or who will attend to assess or evaluate certain clinical
herself financially/factually and that he/she is me or my dependants in the future, to provide information, in the event that you are
dependent on me for family care and support. GEMS and/or its agents with such information subject to such a clinical assessment;
5. I understand that neither my registered as it may require. I expressly grant GEMS the 17.7. For administrative, historical, research and
dependants nor I may belong to two medical right to access my information and that of my statistical purposes if required; and
schemes at the same time. dependants as and when it is necessary. 17.8. to enable benefit confirmation(s) to be
6. I undertake to notify GEMS of any change in the 13. I authorise GEMS on my behalf and that of my performed and to facilitate electronic
circumstances or details of my dependants within dependants to process, which includes collection claims submissions; and
30 days of such change occurring. and storage, of our personal information, which 17.9 For any other lawful purpose.
7. I acknowledge that, in the event of termination includes our health and biometric information as 18. I warrant that when I supply personal information
of membership, I will be required to refund GEMS well as information related to any fraudulent to GEMS about my dependants, I have received
any sum of money which has been paid by the behaviour by us, and which information has been their permission to share such information with
Scheme. supplied by us to GEMS or which GEMS may GEMS for the purposes set out herein and any
8. I understand the benefits that my dependants lawfully collect from any third party, for the other related purposes. If you are giving consent
and I will be entitled to on our selected benefit purposes specified above. for a minor, you confirm that you are a competent
option and confirm that I have had an opportunity 14. I consent to the recording of all conversations person in respect of such minor and that you
to consider such benefits and raise any queries between myself and/or any of my dependants have authority to give their consent for them.
pertaining thereto. and GEMS, its agents or contracted parties, and 19. I authorise GEMS to engage me to confirm my
9. The total monthly contributions that I will be acknowledge and agree for all information most recent contact details as a member of the
expected to pay have been explained to me prior obtained through these conversations to form Scheme. I understand that GEMS will use this
to me making this application and I understand part of the records of GEMS. In addition, I information to communicate pertinent information
that it is my responsibility as a member to make consent to all these records remaining the sole to me.
sure that GEMS receives my total monthly property of GEMS and its agents and which 20. I warrant that all and any information supplied in
contribution, failing which my membership and/ records may be retained for such periods as this application form is, to the best of my
or benefits may be suspended or cancelled. provided for in the Rules and the relevant knowledge and belief, true, correct and complete.
10. I hereby authorise and instruct my employer to legislation. 21. I have read and understood the terms and
deduct from my remuneration, any funds for my 15. I understand that GEMS will only pay claims if conditions as contained herein and acknowledge
benefit after I cease employment, or any other such claims are, in GEMS’ sole discretion, that my dependants and I shall be bound by
sums due by me to my employer, any such deemed valid and comply with the Registered these terms and conditions as well as the
amount(s) that I may owe to GEMS from time- GEMS Rules. Registered GEMS Rules, and my signature
to-time and to pay such amounts to GEMS. 16. I am aware that GEMS reserves the right to below binds my dependants and I thereto.
Insofar as may be necessary, I hereby authorise impose waiting periods on any beneficiary
you to issue and deliver payment instructions to (myself or any of my dependants). GEMS will
my bank for collection against my above- notify me should any of these waiting periods
mentioned bank account. apply to me and/or any of my registered
dependants, based on the information provided
in this application.

I have read and understood the above statements. I have had an opportunity to question and consider these and I agree to the responsibilities
entrusted to GEMS. My signature below confirms that I give permission to the above on my and my dependants’ behalf.

Signature of main member Date nnnnnnnn

D DMMY Y Y Y

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