"*" indicates required fields Oncology Claims This process will allow you to submit any current and future oncology accounts directly to us without having to complete post treatment claim form every time you are notified of any outstanding oncology shortfalls. Policyholder DetailsName* Name Surname ID or Passport number*Cinagi Policy Number Account Details Please use the box below to upload your most recent outstanding accounts* Drop files here or Select files Max. file size: 3 MB. Please use the box below to upload your most recent medical scheme claim statement* Drop files here or Select files Max. file size: 3 MB. Declaration & Submission By providing the information in this form you agree that : Subject to approval by Cinagi, all benefits relating to the co-payment in question will be ceded to Cinagi. Any additional claim/s will be required to be submitted by yourself by means of the standard Cinagi Claims process. To assist Cinagi in obtaining any documentation relating to the fee/s charged by the facility (This could be required after discharge) Negotiate with any of my medical service providers on the fees that they have charged. 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. Have the right to communicate with you electronically about any changes or general information relating administrative processes or changes to your policy benefits and premiums. 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. You further agree that: Cinagi is providing the Co-Payment Claim Optimiser guarantee based on full disclosure as required on your original application for cover. If Cinagi has provided any guarantee under this service and it is subsequently discovered that non-disclosure of pertinent information would have resulted in a waiting period being applicable to your cover, then you agree that the guarantee can be withdrawn or that if any payments have been made to a provider by us on your behalf, that such amounts will be paid back to us. 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’ relevant personal information, you hereby confirm that you are duly 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. Consent* I agree to the above Terms and Conditions Δ