Apply today. Please note Akiva prioritises applications of those earning R13 500 per month or less and who have chronic medical conditions. Exceptions will be considered on a case-by-case basis. "*" indicates required fields Applicant DetailsFull Name* ID number* Age*Date of Birth* MM slash DD slash YYYY Contact Number*Email* Town you reside in* Supporting Documentation Please upload a recent copy of the following documentsIDMax. file size: 64 MB.3 months' bank statementsMax. file size: 64 MB.Proof of residenceMax. file size: 64 MB.Dependent DetailsIf you have more than 1 dependent please complete dependent's details at the bottom of the formDependent Full Name Dependent Date of Birth MM slash DD slash YYYY ID number AgeRelationship to main applicant HiddenPlease check the box if you have multiple dependents. Please check the box if you have multiple dependents. Dependent Full Name Dependent Date of Birth MM slash DD slash YYYY ID number AgeRelationship to main applicant Employment DetailsAre you employed?* Yes No Please tell us where you work and for how long you have been there?Are any of your dependents employed?* Yes No Where and for how long?Personal and Joint Family Income*Personal and Joint Family Expenses*Medical Situation and HistoryPlease give us a brief overview of your and your dependents’ medical situation and history including comorbidities*Date of diagnosis MM slash DD slash YYYY Diagnosing doctor Diagnosis fileMax. file size: 64 MB.Medication on presently and in the pastAllergiesHave you or your dependents ever been hospitalised, when and what for?*Family Medical Aid HistoryPlease tell us what medical aids you and your dependents have been on in the past 5 years. When did you leave the medical aid?*Family Rabbi DetailsName* Number*By submitting this application I hereby authorise Akiva Medical and its representatives to contact and request pertinent personal information from various communal organisations and references identified during the process of my application to Akiva Medical.* By submitting this application I hereby authorise Akiva Medical and its representatives to contact and request pertinent personal information from various communal organisations and references identified during the process of my application to Akiva Medical. Family Doctor DetailsName* Number*Email By submitting this application I hereby give permission to my Doctor and his/ her staff to disclose my personal information relating to my medical aid application to Akiva Medical and its representatives.* By submitting this application I hereby give permission to my Doctor and his/ her staff to disclose my personal information relating to my medical aid application to Akiva Medical and its representatives. Community AssistancePlease tell us about any community assistance that you currently receive from organisations such as Yad Aharon, The Chevra Kadisha etc.*Untitled* I hereby consent to other community organisations, including but not limited to the Johannesburg Jewish Helping Hand and Burial Society ("The Chev") and its affiliated organisations sharing my personal information, including special personal information as defined in the Protection of Personal Information Act No. 4 of 2013 with Akiva Medical NPC ("AKIVA") insofar as such information is required by AKIVA to process my Medical Aid Application. Co-Sponsor Details Akiva funds up to 50% of members' medical aid premiums. The balance will need to be funded by the member themselves or a co-sponsor secured by the member. Rare exceptions may be made on a case by case basis following a comprehensive needs analysisWill Co-Sponsor be* Yourself Friend Relative Name* Number* Email* By submitting this application I hereby confirm that all information submitted by me is accurate and complete and may be relied upon by Akiva Medical and its representatives to undertake a comprehensive needs assessment with respect to my application. I acknowledge that Akiva Medical may accept or reject my application for assistance towards basic hospital cover at its sole and absolute discretion and that Akiva Medical will require up to a 50% co-sponsorship of my monthly medical aid premium which I undertake to assist in securing to the best of my ability.* By submitting this application I hereby confirm that all information submitted by me is accurate and complete and may be relied upon by Akiva Medical and its representatives to undertake a comprehensive needs assessment with respect to my application. I acknowledge that Akiva Medical may accept or reject my application for assistance towards basic hospital cover at its sole and absolute discretion and that Akiva Medical will require up to a 50% co-sponsorship of my monthly medical aid premium which I undertake to assist in securing to the best of my ability. Name* Signature* * * I have read and accept the Terms & Conditions Additional Dependent Details (if required)Dependent Full Name Dependent Date of Birth MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY ID number AgeRelationship to main applicant Additional Dependent Details (if required)Dependent Full Name Dependent Date of Birth MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY ID number AgeRelationship to main applicant Additional Dependent Details (if required)Dependent Full Name Dependent Date of Birth MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY ID number AgeRelationship to main applicant Additional Dependent Details (if required)Dependent Full Name Dependent Date of Birth MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY ID number AgeRelationship to main applicant Additional Dependent Details (if required)Dependent Full Name Dependent Date of Birth MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY ID number AgeRelationship to main applicant
