Diaspora Meds Insurance Membership Application Form

DEPENDANTS INFORMATION (ATTACH COPIES OF ID, VALID PASSPORT OR BIRTH CERITIFICATE FOR ALL MEMBERS ON THIS FORM) 

NB: Enter exact number of dependants above to get more dependant entry sections

CONTACT DETAILS OF A RECIPIENT OF ALL CORRESPONDENCE IN ZIMBABWE

DETAILS OF YOUR FAMILY GENERAL PRACTITIONER IN ZIMBABWE (IF APPLICABLE)

CHRONIC DISEASE CONDITION DECLARATION 

It is most important that the following questions be answered as thoroughly as possible, by selecting the specific condition. The answers to these questions will be treated as confidential. It is important to note that any medical condition, of which you are aware, not disclosed in this application, can be excluded from benefit. You can verify or double check a condition from our list of Condition examples here

 CONFIDENTIALITY CLAUSE

CellMed certifies all the information submitted herein will remain confidential and intended solely for the use of Diaspora Plan membership onboarding.

SECTION VIII

DECLARATION

I certify that the information given above was submitted willfully and is correct. I agree that should my application be accepted, l will abide by the rules, benefits and regulations set by CellMed Health Medical Fund (CellMed); details of which is available on request. Agreeing below signifies the basis of contract between CellMed and myself.