SUSPENDED FORM

Patient Information

Name

Surname

Email

Contact Number

Date of Birth

Physical Address

Diagnosis (State undiagnosed if not known)

Symptoms

Are you on Medical Aid?

If you are on medical aid, which one?

Please specify your selected medical aid plan

Medical Aid Number

Is there any other information you feel we should be aware of?

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Guardian/Parent details (In case patient is a minor)

Name

Surname

Alternative Email

Alternative Contact Number

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Primary Doctor's Details

Doctor's name

Doctor's address

Doctor's Email

Doctor's Contact Number

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RareAssist payment options

Which RareAssist service are you signing up for? (Please note that there is a once-off admin fee of R200 for all applications)

Basic Assist plan: R180 per month (claims and follow ups) Premium Assist plan: R270 per month (claims, follow ups, benefit applications and renewals, special motivations and applications) Ad Hoc Service: R3250 Initial application for benefits with medical aid scheme (Simple) Ad Hoc Service: R5200 Initial application for benefits with medical aid scheme (Complex) Ad Hoc Service: R2600 Annual reauthorization of benefits Ad Hoc Service: R6500 Ex-gratia applications Ad Hoc Service: R6500 PMB Applications

PLEASE NOTE

Once you have registered with us, your completed form will be sent to our admin team who will draw up an invoice including the once off signup fee of R200, as well as your selected plan or ad hoc service fee. On receipt of payment, your details will be captured and handed over to a case management consultant, who will be in touch with you within 48hours. Please send your proof of payment to admin@rarediseases.co.za

Our Process

Billing Cycle

We start working on your case as soon as we receive payment. Our billing cycle runs from the 1st – 30th/31st of the month. Payments received within the month are allocated to that particular month (regardless of date received) with new invoices being sent on the 1st/next working day of the new month. We do not pro-rata the service or the invoices. If you can wait for assistance, we suggest only making payment at the beginning of the new month, in order to receive the benefit of a full months service.

Billing Date

Bill me on the 1st of next month (I can wait until next month for assistance) Bill me now (I require assistance asap)