Sanlam Cashless Co-Payment Claim Submission Form

SanlamCashless Co-Payment Claim Submission Form

Authorisation Number

Sanlam Gap Policy Number

Policyholder Name

Policyholder ID

Patient Name

Patient ID

Medical Scheme

Medical Scheme Number

Date of Admission

Co-payment Amount

Hospital Name

Hospital Practice Number

Invoice Number

Procedure Code

ICD 10 Codes

Name of Mediclinic staff member submitting claim

Mediclinic Staff Member Email

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This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme.

This Policy is not a substitute for Medical Scheme membership.

Kaelo Risk (Pty) Ltd is an authorised financial services provider (FSP 36391)

Insurance Products are underwritten by Centriq Insurance Company Limited (“Centriq”) a licensed non-life insurer and authorized Financial Services Provider (FSP 3417)