Contact us

Tel: 0860 99 88 77, PO Box 784262, Sandton, 2146, www.discovery.co.za

Permission to change banking details

This is a form to change banking details.

What you must do

Please go through these two steps:
Step 1: Fill in the form
Step 2: Sign the application form.
When you sign this application, you confirm the information provided is true and correct.

How to complete this form

• Please use one letter per block, complete with black ink and print clearly.
• To avoid administration delays, please make sure this form is completed in full.
• Once complete, please fax your form to 011 539 2766.

1. What would you like to change?

Debit order details Claim payment details Both

2. Main member details

Membership number
ID number
Telephone (H) (W)
Cellphone
Email
I, (first and last name), as the main member
give Discovery Health permission to change my banking details.

3. Previous account details

Accountholder
Bank
Account number
Type of account Cheque Savings
_ _ _
Branch number Branch name
91485 11/09

Page 1 of 2 Discovery Health (Pty) Ltd administers the Discovery Health Medical Scheme Registration number 1997/013480/07 An authorised financial services provider
 4. New account details
Y Y M M
What date should we start using the new banking details? 2 0 0 1

Please note that we cannot accept credit card details.

Accountholder
Bank
Account number
Type of account Cheque Savings
_ _ _
Branch number
Branch name
Account number
Please print your account number in the first row and circle the relevant blocks.

0 0 0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 7 7 7 7 7
8 8 8 8 8 8 8 8 8 8 8
9 9 9 9 9 9 9 9 9 9 9

Your banking details will only be changed if:

1. All the previous details you have supplied on this form correspond with the existing information on Discovery Health’s system; and
2. The request has been signed by the main member.

Y Y M M D D
Signed at (town or city) on 2 0

Signature of Signature of
main member accountholder

If the accountholder differs from the main member, the scheme reserves the right to obtain a bank confirmation.

Page 1 of 2 Discovery Health (Pty) Ltd administers the Discovery Health Medical Scheme Registration number 1997/013480/07 An authorised financial services provider