Please attach the letter of consent signed by the member. Supported file types are 3g2, 3gp, 7z, acc, avi, bmp, csv, doc, docx, dot, f4v, flac, flv, gif, jpeg, jpg, m4a, m4v, mov, mp3, mp4, mpa, mpeg, mpg, msg, odt, ogg, ogv, pdf, png, pps, ppsx, ppt, pptx, rar, rtf, svg, tif, tiff, txt, wav, wma, wmv, xls, xlsx, zip
Member First Name *
Member Last Name *
Membership Number*
Medical Doctors’ Practice Name*
Member Title * Select Member TitleMrMsMrsDrProfThe Hon JusticeUnknown
Member Postal Address*
Member Complex/Building Address
Member Postal Code*
Member Postal Suburb *
Member Postal City*
Member Province * Select Member ProvinceEastern Cape Free State Gauteng Kwazulu-natal Limpopo Mpumalanga North West Northern Cape Western Cape Unknown
Member Telephone Number
Member Cell Number*
Member Email Address *
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Complainant First Name*
Complainant Last Name *
Complainant Title * Select Title ComplainantMrMsMrsDrProfThe Hon JusticeUnknown
Complainant Postal Address *
Complainant Complex/Building Address
Complainant Suburb *
Complainant City *
Complainant Postal Code *
Complainant Province * Select Complainant ProvinceEastern Cape Free State Gauteng Kwazulu-natal Limpopo Mpumalanga North West Northern Cape Western Cape Unknown
Complainant Telephone Number
Complainant Cell Number *
Complainant Email Address *
I hereby lay a complaint against* Select Lay A Complaint AgainstIndividual BrokerBrokerage OrganisationAdministratorMedical SchemeManaged Care Organisation
Facts of the complaint
Details of dispute resolution processes followed with the Medical Scheme / Administrator / MCO / Broker *
What recourse do you require? *
Please attach supporting documents
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