Submit Membership Form

By taking the time to fill out this form you are taking the first step to securing a Healthy future for you and or your loved ones. You are required to fill out six sections of the Form to make sure all yours and or your loved ones information is accurately captured.

This form will not be processed if it is not completed in full. If subscriptions are not paid in advance by the 1st of every month, benefits will be suspended.

1
Section
I
2
Section
II
3
Section
III
4
Section
IV
5
Section
V
6
Complete

SECTION I - PAYER DETAILS RESPONSIBLE FOR ACCOUNT PAYMENT

Payer/Sponsor Name *Please enter your name

Contact Number *Please enter number we can use to contact you

Email Address *Please enter your email address

*Number of Members to be paid for How many members do you wish to pay Medical Insurance for? (5 max)

SECTION IV - DETAILS OF YOUR FAMILY GENERAL PRACTITIONER IN ZIMBABWE (IF APPLICABLE)

General Practitioner NamePlease enter the name of your General Practitioner

General Practitioner PhonePlease enter the phone of your General Practitioner

General Practitioner Street AddressPlease enter the address of your General Practitioner

General Practitioner CityPlease enter the city of your General Practitioner

SECTION V - CHRONIC DISEASE CONDITION DECLARATION

It is most important that the following questions be answered as thoroughly as possible, by selecting the specific condition. The answers to these questions will be treated as confidential. It is important to note that any medical condition, of which you are aware, not disclosed in this application, can be excluded from benefit. You can verify or double check a condition from our list of Condition examples here

*Do you or any of your dependants to being registered have any pre-existing medical conditions?

Yes

*ConditionsPlease enter all the name(s) of pre-existing medical condition(s) the member has

*Source of Funds

SECTION VI - CONFIDENTIALITY CLAUSE

CellMed certifies all the information submitted herein will remain confidential and intended solely for the use of Diaspora Plan membership onboarding.

SECTION VII - CONFIDENTIALITY CLAUSE

I certify that the information given above was submitted willfully and is correct. I agree that should my application be accepted, l will abide by the rules, benefits and regulations set by CellMed Health Medical Fund (CellMed); details of which is available on request. Agreeing below signifies the basis of contract between CellMed and myself.

Signature

Bringing your health smile back

Emergency 24/7

Submit Membership Form