Membership Registration Form - Ist Medical Scheme Clinic (Page 2 of 2) in pdf

IST MEDICAL SCHEME CLINIC

Belia Klaassen, MD

P.O. Box 2651

Ype Smit, MD

Dar es Salaam, Tanzania

Tel.+255 22 2601307/08

Fax +255 22 2600127

Mobile: 0754-783393

Email:

PLEASE PROVIDE US WITH INFORMATION OF ALL SECONDARY MEMBERS APPLYING FOR MEMBERSHIP

LAST NAME

FIRST NAME

DATE OF

GENDER

RELATIONSHIP

TELEPHONE

BIRTH

M/F

þÿ

Terms and Conditions

1. All invoices will be sent through the mode requested, however, it is the primary member’s responsibility to

confirm with Accounts Department and settle any outstanding medical bill within 30 day credit period.

2. If an account has an outstanding balance of more than 2 months, the members, upon their visit, will be directed to

Accounts Department to discuss the payment plan.

3. After receiving two reminders, if the account remains unsettled for a period of more than 3 months, IST Medical

Clinic will offset the account balance against the security deposit. The members will then be classified as private

patients and have to pay cash on their next visit to the clinic. The membership will be reactivated once the account

has been settled and security deposit has been paid.

3. If the primary member decides to cease membership with IST Medical Clinic, a two week prior notice will be

required for the request to be processed. Thereafter, if the account has no outstanding balance, the security deposit

will be refunded in the same currency as it was initially paid.

4. For family membership, a maximum of six individuals can be registered under the scheme.

5. Please submit a copy of your passport or National ID for our records.

6. Members that require insurance claim forms to be filled out by the doctor, must fill the top portion of the form

and submit during their consultation. The forms will be ready for pick up at the Accounts Department only if the

account has been settled.

Please sign below to indicate the following:

All the information provided is true and correct

I have read and understood the terms and conditions above

I accept financial responsibility in full for this account

SIGNATURE OF PRIMARY MEMBER

DATE

OFFICIAL USE ONLY

Paid by Cash /Chq /Credit Card __________________________

Receipt No.: ______________________

Signature: __________________________________________

Date: ___________________________

Membership Registration Form - Ist Medical Scheme Clinic Page 2

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