International_student_renewal_form_fillable

International student renewal form 2023
Important notes:
• Momentum Medical Scheme is a medical scheme registered under the Medical Schemes Act, 131 of 1998.
• Momentum Medical Scheme is administered by a separate company, Momentum Health Solutions (Pty) Ltd (Administrator), part of Momentum
Metropolitan Holdings Limited.
• Momentum Medical Scheme will only consider membership on receipt of a fully completed application form.
• Compulsory documents to be submitted with your application:
- Enrollment letter or current study visa
- Proof of payment (see banking details under section 5). Please use your membership number as the reference number when paying the
contribution
• Please submit the completed and signed forms as well as the documents listed above, via email to studentapplication@momentum.co.za.
• Should we not receive all the required supporting documents, it will delay the finalisation of your application.
1: Membership details
Current membership number Renewal start date 0 1 M M Y Y Y Y
Number of months of medical aid cover required (minimum of 6 months)*
*We recommend that you check the minimum period of cover with your academic institution and embassy, to avoid a delay in your medical aid
cover.
2: Principal member’s details

Passport number
Country in which passport was issued
Name of institution where studying
Campus Student number
Title Initials First name
Surname
Date of birth D D M M Y Y Y Y Gender Male Female
Marital status
Race African Coloured Indian/Asian White Other
I would prefer not to disclose my race
We collect race information for statistical purposes for the Council for Medical Schemes.
Please provide either your South African or international cellphone number, as well as your email address. We cannot process your application without
this information.
Cellphone number
International cellphone number
Email address
Please note that the email address you provide will be used when the Scheme communicates with you.
Address in South Africa
Home address*
Postal code
Postal address (if different)
Postal code
* You may use the address of the institution where you are studying if you do not yet have an address in South Africa.
STUDENTHEALTH 0480123E | International student renewal form | 2023 1/2

3: Dependant particulars
I wish to keep my dependants on my medical scheme membership. Yes No
Please complete an application for Addition of Dependants form
• if you wish to change your dependant details, or
• if there was a break in membership
4: Option
Ingwe Option Hospital provider: Any hospital Chronic and Day-to-day provider: Ingwe Active Network
5: Banking details to pay your contributions to Momentum Medical Scheme

(Please use your membership number as reference)
Account Name Momentum Medical Scheme Account Name Momentum Medical Scheme Account Name Momentum Medical
Name of Bank First National Bank Name of Bank Standard Bank Scheme
Branch Name Global Transactional Services Branch Name Florida Road Name of Bank ABSA
- Durban Type of Account Current Branch Name Killarney
Type of Account Current Account Number 050 810 995 Type of Account Current
Account Number 62127765371 Branch Code 042726 Account Number 4060933128
Branch Code 22 36 26 Bank Code / Swift Code SBAZAZAJJ00720535 Branch Code 632005
Bank Code / Swift Code FIRNZAJJ Bank Code / Swift Code ABSAZAJJ
6: Statement by principal member

1. I apply for my dependants and I to join Momentum Medical Scheme (the Scheme) administered by Momentum Health Solutions (Pty) Ltd (Administrator)
and agree to familiarise myself with, and be bound by, the Rules of the Scheme (the Rules) if my application for membership is accepted. I understand
that I may request to inspect the Rules and that, in the event of a dispute, the Rules will be decisive.
2. I acknowledge that if my dependants and I do not disclose all the information that is relevant to the assessment of this application or if I and my
dependants submit fraudulent claims, it will make any contracts to which this application relates null and void. The Scheme may, at its discretion,
recover any amounts paid to me or any service provider on my behalf.
3. I irrevocably grant my permission to any physician, person or party who may be in possession of, or obtain information concerning my health, or that
of my dependants, to divulge such information to Momentum Medical Scheme, also after my death.
4. I undertake to pay any amount due to Momentum Medical Scheme, on demand. Failure to pay any debt due to the Scheme may result in suspension
or termination of membership and/or handover to a third party for collection.
5. I will notify the Scheme if I or any of my dependants are living with HIV/Aids within 14 days of activation of membership.
6. I will notify the Scheme should I or any of my dependants require hospitalisation for a non-emergency event at least 48 hours before the event.
I acknowledge that failure to do so will result in a co-payment being applied as contained in the Scheme Rules.
7. I undertake to give a calendar month’s notice should I wish to terminate my membership and/or terminate the membership of my dependants..
8. I consent to the recording of all conversations between me and the Scheme or the Administrator, and all information obtained through these
conversations will form part of the Scheme’s and the Administrator’s records. I also consent to all these records remaining the sole property of the
Scheme and the Administrator.
9. As an international/foreign student, I confirm that I have complied with the study visa/permit regulations as determined by the South African Home
Affairs Immigration Act No. 13 of 2002. I consent to Momentum Medical Scheme sharing my membership details, as well as my personal details,
including my name, date of birth and passport number, with contracted third parties for the purposes of verifying my membership in accordance with
the study visa requirements, as per the Immigration Act.
10. I understand that Momentum Medical Scheme further reserves the right to review my membership should it be found that I failed to submit valid,
accurate or complete documentation in support of my application for membership. I acknowledge that the Scheme reserves the right to verify that the
documents submitted in support of my application for membership are valid, accurate and complete. I further acknowledge that the Scheme reserves
the right to terminate my membership should the documentation be found to be fraudulent.
11. For female applicants: I understand that if I had a break in membership and I find out that I am pregnant before signing this renewal application, a
12-month exclusion for pregnancy and confinement may apply.
12. I confirm that I am not earning a taxable income of more than R825 per month.
13. I confirm that all previous documents that I have completed and submitted to Momentum Medical Scheme, where I have agreed to terms and
conditions and given the Scheme consent to process my and/or my dependants’ personal information, remain in full force and effect. Momentum
Medical Scheme complies with the Protection of Personal Information Act 4 of 2013 (POPIA) when processing your personal information. This
means that keeping your information confidential and safe is the Scheme’s top priority. Momentum Medical Scheme’s Privacy Policy governs the
way the Scheme treats your personal information. The Privacy Policy is subject to change from time to time and you can access the latest version at
momentummedicalscheme.co.za/privacy-policy/.
Signature of principal member Date D D M M Y Y Y Y
For office use (you do not need to complete this section)
Broker code Broker house code

Group code Institution code
Momentum Medical Scheme 201 uMhlanga Ridge Boulevard Cornubia 4339 PO Box 2338 Durban 4000 South Africa
Client Service and Authorisation 0860 11 78 59 member@momentumhealth.co.za studenthealthcare.co.za
Registered in terms of the Medical Scheme Act No 131 of 1998
STUDENTHEALTH 0480123E | International student renewal form | 2023 2/2

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International student renewal form 2023

2: Principal member’s details

STUDENTHEALTH 0480123E | International student renewal form | 2023 1/2

5: Banking details to pay your contributions to Momentum Medical Scheme

6: Statement by principal member

Signature of principal member Date D D M M Y Y Y Y

For office use (you do not need to complete this section)

Broker code Broker house code

STUDENTHEALTH 0480123E | International student renewal form | 2023 2/2

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