Maternity Application Form

declare that all the information supplied is to my best knowledge true and correct. I may not hold the Managed Care Company, liable for any information that I have omitted. I consent that the supplied information may be shared amongst contracted health care personnel in order to grant me the best possible care based on the program and protocols outlined by Kaelo Prime Cure.

I consent to the health care workers responsible for my treatment and/or management in terms of the Maternity Program providing the Programme’s health care workers with the clinical information pertaining to my current pregnancy, and the treatment and management thereof. I further consent to the healthcare providers sharing the above-mentioned information with any other health care worker involved with my care or management (including hospital risk management professionals appointed by the Medical Scheme/Health Insurer or the Scheme’s administrator). Consent is provided on the grounds that no clinical information regarding my health condition will be available to my employer(s) or any other person not involved in my health care, without my express written consent.

I acknowledge that whilst Kaelo Prime Cure shall use its best endeavours to uphold the confidentiality of all information disclosed to it, Kaelo Prime Cure shall not be liable for any claims by me or my dependents arising from any unintentional unauthorised disclosure of my personal information, my medical information pertaining to my health condition and the treatment and management thereof to a third party; or as a result of Kaelo Prime Cure having to use ICD 10 codes when filing a claim for payment with the Medical Scheme.

I acknowledge that my cover and benefits will be limited to those set out in my Policy Documents or in accordance with the rules of my medical aid plan.