Momentum Health Ingwe Active Members

Radiology request form for chest x-ray for visa purposes 2019

Important notes:
• This form is only applicable for members on the Ingwe Active option who require a chest X-ray for South African visa approval purposes.
• A referral from a GP is not required.
• This form must be accompanied by the Department of Home Affairs form.
• In the event of any abnormalities detected on the X-ray, please refer the member to their Ingwe Active Primary Care Network GP.

Section 1: Patient’s details

Membership number 9 1 2 4 6 4 7 5 0 Option name I N G W E A C T I V E
Principal member’s full name A b d u l R a h m a n M o s a m e e m
Patient’s full name A b d u l R a h m a n M o s a m e e m
Dependant code Gender Male Female Date of birth 1
D 5
D - 0
M 8
M - 1
Y 9
Y 8
Y 7
Y

Home telephone number 0 6 3 0 7 8 2 5 7 3 Cellphone number 0 6 3 0 7 8 2 5 7 3

Postal address J P D u m i n y C o u r t F l a t n o : 1 3
R o s e b a n k , C a p e t o w n Postal code 7 7 0 0

Section 2: Referring practice number

Please use practice number 9324823 for submission of the claim.

Section 3: Test details

Tariff code: 30100
Description: X-ray of chest, single view

Section 4: Tariff value for chest x-ray

Tariff value: R434.40

Momentum Health 201 uMhlanga Ridge Boulevard Cornubia 4339 PO Box 2338 Durban 4000 South Africa
Client Service and Authorisation 0860 102 493 member@momentumhealth.co.za ingwehealth.co.za
Registered in terms of the Medical Scheme Act No 131 of 1998

0560219E
STUDENTHEALTH
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