BP Medical Aid Society

Forms

Only full-time employees of BP Southern Africa (Pty) Ltd are eligible to join BP Medical Aid Society as principal members.

Membership

 picture_as_pdf Application for membership and record amendment form

 picture_as_pdf Application for continuation of membership (post-retirement)

 picture_as_pdf Contact details of dependants over the age of 18

 picture_as_pdf Consent form: Authorisation for disclosure of information

 picture_as_pdf Banking details form

 picture_as_pdf Bank mandate form for contributions

 picture_as_pdf Grievance form

 picture_as_pdf Application for ex gratia assistance

 picture_as_pdf Affidavit for declaration of income

 picture_as_pdf Affidavit for the principal member or partner's siblings, parents, grandchildren, nephews, nieces and children over 21

Programme enrolment

 picture_as_pdf Palliative care application form

 picture_as_pdf HIV Programme application form - for adults

 picture_as_pdf HIV Programme application form - for children

 picture_as_pdf Maternity Programme application form

 picture_as_pdf Prescribed minimum benefit treatment plan application form

 picture_as_pdf  Integrated Care Programme application form

Authorisations

 picture_as_pdf Medicine Risk Management application form

 picture_as_pdf Nursing care benefits application form

 picture_as_pdf Chronic medication advance supply request form

 picture_as_pdf Acute dialysis request and update application form

 picture_as_pdf Chronic renal dialysis application form

			Years without Medical Aid cover
1	Main Member
{{$index + 2}}	Adult Dependant

Years without Medical Aid cover

Main Member

Adult Dependant

BP Medical Aid Society

BP Medical Aid Society

Forms

Membership

Programme enrolment

Authorisations

Cookies

Required information

Practice Name

Practice Number

Medical Aid

Membership Number

Patient's Name

Patient's Birthdate

Patients Dependant Code

Date

ICD Code

Required information

Membership Number

Patient Full Name

Birthdate of Patient

Hospital Practice Number

Doctor's Practice Number

CPT4 number or Tariff code

Date of Admission or Procedure date

Doctor's Costs

BP Medical Aid Society

BP Medical Aid Society

Forms

Membership

Programme enrolment

Authorisations

Cookies

Main member

Dependants

Years Without Medical Aid Cover

Required information

Practice Name

Practice Number

Medical Aid

Membership Number

Patient's Name

Patient's Birthdate

Patients Dependant Code

Date

ICD Code

Required information

Membership Number

Patient Full Name

Birthdate of Patient

Hospital Practice Number

Doctor's Practice Number

CPT4 number or Tariff code

Date of Admission or Procedure date

Doctor's Costs