Quote - Joint Decisions in Health

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Services
Medical Schemes
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Quote
Latest News
About
Contact
- Complaints Contact Form

Need Analysis - Start
Family Size
Affordability
In Hospital Needs
Out of Hospital Needs
Gap Cover Needs

Email

Needs Analysis - Individual

Name *

Surname *

Contact Number *

E-mail Address *

Have you been covered by a South African registered medical scheme in the last 90 days? *

Yes No

Have you (and all your beneficiaries) been active members on a South African registered medical scheme for the past 24 months? *

Yes No

Family Size

Main Member *

Spouse *

Number of spouses

Number of Child Dependent (0 to 20) *

Number of Children 0 to 20

Number of Additional Adults (21 to Over) *

Number of additional adults over 21

Total Number of Beneficiaries

Total:

Late Joiner Penalty Questions

LJP - Beneficiary 1

Beneficiary Name

Current age

Number of years on a SA registered medical scheme since age 21

Affordability

Are you moving from another medical aid? *

Yes No

Are enhanced benefits required? *

Yes No

What is your maximum monthly medical aid contribution you are happy to pay? *

In Hospital Needs

In Hospital Needs

Chronic Medication Needs

Chronic medication needs

Oncology Requirements

Is there a history of cancer treatment in your immediate family? *

Planned Hospitalizations

Do you have any planned hospitalizations *

Please disclose any additional medical details that may influence the advice being provided:

Out of Hospital Needs

I want a hospital plan only

I want a plan that offers visits to network providers

I require extensive out of hospital cover

I require low level out-of-hospital cover

Gap Cover Needs

Specialist re-imburstment rate

Note - Medical aid rate are at 100%. Private rates charged by specialists are generally between 200% and 300%.

Is GAP cover for compulsory scheme co-payments required (such as admission fees and procedure specific co-payments)?

Yes No

Is GAP cover for cancer related shortfalls required?

Yes No

Is GAP cover for hospital related sub-limits required?

Yes No

Address: 6 Werda Street
Durbanville
7550
Phone: 021 970 2599
Email: info@jdhfin.co.za

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Registration number: CK2010/059077/23
Authorised FSP: 42161

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