Family Practitioner Nomination Form
Dear SAMWUMED member, please complete the form below in order to nominate your family practitioner of choice for 2024. Please note that you are allowed to nominate up to two practitioners every 6 months.
Section 1: Main Member Details
Your Full Name
*
First Name
Last Name
ID Number
*
Membership Number
*
Please enter your membership number as it appears on your scheme membership card.
Email Address
*
example@example.com
Cellphone Number
*
Please enter a valid phone number.
Back
Next
Section 2: Main Member Family Practitioner Nomination
Please select your preferred Family Practitioner from the SAMWUMED Family Practitioner Network List below. Should your Family Practitioner not be listed, you can still provide the name of your preferred Family Practitioner outside network, but you are reminded that visiting your Family Practitioner might then incur a co-payment as their rates may differ from the negotiated network tariffs. You may nominate up to two Family Practitioners. If your Family Practitioner is not listed, we encourage you to request your Family Practitioner to join our network by phoning the Scheme at: 0860 104 117.
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional)
Provide Second Family Practitioner Details If Not Listed Above (Outside Network) (Optional)
Full Name
Practice Number
Back
Next
Section 3: Spouse / Partner and Dependent Family Practitioner Nomination
Please select the preferred Family Practitioner from the list below. Should the Family Practitioner not be listed, you can still provide the name of the preferred Family Practitioner outside network, but you are reminded that visiting that Family Practitioner might then incur a co-payment as their rates may differ from the negotiated Scheme network tariffs. You may nominate up to two Family Practitioners for each of your dependents.
How many dependents do you have?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Back
Next
Dependent 1
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Dependent 2
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Dependent 3
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Dependent 4
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Dependent 5
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Dependent 6
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Dependent 7
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional)(Outside Network)
Full Name
Practice Number
Dependent 8
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Dependent 9
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Dependent 10
Full Name
*
First Name
Last Name
ID Number
Relation
*
Please Select
Spouse
Child
Parent
Grandparent
Other
Select Family Practitioner from family practitioner network.
Provide Family Practitioner Details If Not Listed Above (Outside Network)
Full Name
Practice Number
Select Second Family Practitioner from family practitioner network (Optional).
Provide Second Family Practitioner Details If Not Listed Above (Optional) (Outside Network)
Full Name
Practice Number
Back
Next
Section 4: Acknowledgement & Signature
Signature
*
Signed on:
*
Continue
Continue
Should be Empty: