Cinagi Claim (Medshield) "*" indicates required fields Step 1 of 10 10% Gap Cover - Post Treatment or Procedure Claim To claim against your Cinagi gap cover benefits you need to complete this form and attach all the relevant claim documents once prompted. The supporting documentation that will required is as follows and can be uploaded online while completing this form: The relevant account from the doctor/provider The claims statement from the medical scheme showing how they have processed and paid the above account The first 2-3 pages of the hospital account showing the admission/discharge dates, ICD-10 codes, patient name, etc (if applicable) Claims are processed continuously and are paid daily. Once we have finalised your claim we will issue you with a claim remittance via e-mail. Important : Cinagi can’t start with the assessment of your claim until we have received a fully completed claim form and all the relevant supporting documentation. You can contact us if you need any assistance by clicking HERE . Policy Holder DetailsTitle*MrMrsMsMissInitials*Name* First Last ID or Passport Number*Cellphone Number*Alternative Contact NumberEmail* Enter Email Confirm Email Medical Scheme*Please select your Medical SchemeAlliance MidmedDiscoveryMomentumCAMAFProfmed (PPS)FedhealthMedihelpBonitasBankMedBestMedCape Medical PlanCompCareGEMSGenesisHealth SquaredHosmedKeyHealthLA-HealthMakotiMedshieldMotohealth CareSizweSuremedSasol MedTransmedOTHERBenefit Option*Membership Number*Cinagi Policy Number (If Available) Patient DetailsName* First Last Date of Birth*YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031Gender* Male Female Relation to Policy HolderMain MemberSpouseChildSpecial DependentAdult Details of Medical Service ProvidersName of Doctor*Telephone Number*Practice Number*Treatment Date* DD slash MM slash YYYY Name of Hospital (if applicable)Please provide details or description of the illness & treatment* Document Upload Upload Hospital Account (If Availbale) Drop files here or Select files Max. file size: 5 MB, Max. files: 2. Document UploadUpload the accounts from the various Doctors and/or Service Providers Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 10 MB, Max. files: 5. The claims remittance from your medical scheme This needs to show how they have processed and paid the above doctor’s account. This is also called the ‘claims transaction history report’ which can be downloaded by logging into your medical scheme portal and then clicking on ‘your medical claims’. To view an example of the Fedhealth Member Statement click HERE. Upload Medical Scheme Remittance (If Availbale) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 3 MB, Max. files: 3. Copy Of The Main Member's ID or PassportFile* Drop files here or Select files Max. file size: 2 GB, Max. files: 2. Payment Details Where applicable, we will pay your doctor directly. If you have already paid your doctor, we will refund you.Have you already paid your doctor?*YesNo Please provide your bank account details below : Bank Name*ABSAFNBNedbankStandard BankCapitecInvestecAfrican BankBidvest BankOTHEREnter Bank NameAccount Holder Name*Account Type*CurrentSavingsTransmissionAccount Number*Branch Code* Declaration & Submission By providing the information in this form you agree that Cinagi (Pty) Ltd and its underwriter, Infiniti Insurance Ltd may : To use this information to provide you with administrative and insurance services. To negotiate with any of my medical service providers on the fees that they have charged. To disclose this information to persons and entities that it is necessary to disclose this information to in order to provide you with the aforementioned services. To communicate with you electronically about any changes or general information relating to administrative processes or changes to your policy benefits and premiums or new/upgraded services or products that are available. To only transfer your personal information outside South Africa if you have provided an email address that is hosted outside South Africa or to administer certain services, for example, cloud services and/or the Medical Second Opinion service. To obtain any medical records, medical claims or personal information for myself or my dependants from my/our medical scheme and/or my/our medical service providers, including their sub-contractors who process or transfer the relevant medical records, medical claims and personal information between your medical scheme and your medical service providers To obtain any medical records, medical claims or personal information for myself or my dependants from any medical data bureau or credit bureau who respectively act as aggregators of medical and credit information You further agree that: that all details above as well as any supporting documentation supplied with this claim, are true and correct and that you are aware that any non-disclosure or misrepresentation of any details may result in this claim being rejected or your policy cancelled or voided from inception. •by submitting your dependents’ personal information, you hereby confirm that you are authorised to share such information with us. We will furthermore process their information for the purposes and in the manner as set out in our Privacy Statement if you are submitting this claim for a person under the age of 18 years (a minor), you confirm that you are a competent person and that you have the authority act on their behalf. You also acknowledge that that you have read and agreed to the Cinagi Privacy Statement and the contents thereof. Signed At* City Province Signature*CommentsThis field is for validation purposes and should be left unchanged. Δ