Change my GP - Prime Cure Health

GP Nomination Form

IMPORTANT NOTE: Please note that this GP Nomination Form must be completed in full, or call the Prime Cure contact centre on 0861 665 665. Upon approval, confirmation of change will be emailed to the requestor within 24 hours of receipt.

Principal Member / Policyholder Details

Surname *

First Name *

ID Number / Passport Number *

Cell *

Telephone

Fax

Email *

Member / Policy Number *

Medical Scheme / Health Insurer *

Medical Scheme/Health Insurer Plan

Employer

GP Practice Name *

GP Practice No.

GP Practice Name *

GP Practice No.

Member Signature *

Clear

Dependent Details

First Name

Surname

ID Number/Passport

Dependant Code

GP Practice Name 1

GP Practice No. 1

GP Practice Name 2

GP Practice No. 2

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