Follow the steps to successfully complete the ZA GEMS PMB Request Form.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by filling out Section A: Membership Details. Enter your surname, first name, date of birth, member number, dependant code, daytime contact number, option/plan, ID number, and email address.
3. In Section B: Treatment Healthcare Provider Details, provide the necessary information about your healthcare provider. This includes their surname, practice number, initials, specialty, contact numbers, and email address.
4. Proceed to Section C: Motivation to Waive Rules on Non-DSP. Select one of the reasons for the waiver request from the options provided, such as a new treatment plan or motivation for extra treatment.
5. In Section D: Patient Consent, read the terms carefully, then provide your signature, date, and your name and surname to confirm your understanding and authorization.
6. Complete Section E: Full Treatment Plan. This needs to be filled out by your treating healthcare provider, detailing the procedure or consultation, including NAPPI codes, ICD-10 codes, the PMB condition, description, motivation, and doctor’s signature with date.
7. Once all sections are completed, ensure that any necessary attachments, such as special investigations and lab results, are included. You can then save changes, download, print, or share the form as needed.

Start completing your ZA GEMS PMB Request Form online today for a seamless submission experience.