Health & Meds to the People! Hutano Mishonga Kuvanhu! Impilakahle Imithi Ebantwini! Claim Form MEMBER’S NAME Full Name Member’s Policy Number POSTAL ADDRESS* Street Address City State / Province / Region ZIP / Postal Code CONTACT TEL NO*EMAIL ADDRESS (Optional) Beneficiary’s NAME RELATIONSHIP TO MEMBER Beneficiary’s D.O.B DD slash MM slash YYYY PLEASE ATTACH THE FOLLOWING DOCUMENTS VIA UPLOAD BUTTON, WHATSAPP, EMAIL OR BRING THEM TO OUR OFFICES TOGETHER WITH THIS CLAIM FORM. 1: PRESCRIPTION, 2: MEMBER ID, 3: BENEFICIARY IDFile Drop files here or Select files Max. file size: 512 MB.
