Monthly Member Statement

Statement Date: 31/07/2012

Medical Scheme Details

MEDSHIELD MEDICAL SCHEME
P O BOX 68618
Mr J Oneill
BRYANSTON
PO Box 71749
2021
Die Wilgers
Email Address: member@medshield.co.za
0041
Hospital Authorisation Number: 086 000 2121
Contact Centre Number/Lost Cards: 086 000 2120
Chronic Authorisation Number: 086 010 0608
Web Address: www.medshield.co.za
Member Details
Member Number: 68600048552 Telephone Number(s): 0128110161 0128110042
Previous Member Nr: 68400170534 Cellular Number: 0728902233
Option: Premium Plus Email Address: warhawkjohnny@gmail.com
Option Start Date: 01/10/2009 Pay Point: 686/998/0MO - DIRECT PAYING MEMBERS MO - RA

Member Beneficiary Status

Code Beneficiary Type Beneficiary Name Identity Number Date of Birth Status Scheme Join Date Benefit Date Scheme Left Date
00 Principal Member JOHN ONEILL 7211235275084 23/11/1972 Active 01/05/2005 01/05/2005

Limit Utilisation Summary

Limit Limit Description Limit Type Beneficiary Name Start and End Date Limit Used Available
01 Overall Annual Limit Family 01/01/2012 - 31/12/2012 Unlimited R0.00
13.04 Medication-Flu Vaccinations Beneficiary John (J) 01/01/2012 - 31/12/2012 1 0 1
16.01 Optical-Eye Tests Beneficiary John (J) 01/01/2012 - 31/12/2012 1 0 1
16.08 Optical - Readers Beneficiary John (J) 01/01/2012 - 31/12/2012 R120.00 R0.00 R120.00
62 Medicine-Chronic - PMB only Family 01/01/2012 - 31/12/2012 R0.00
95 PMB Family 01/01/2012 - 31/12/2012 Unlimited R0.00
The limit usages reflected are as at the statement generation date, and might have been affected by claims processed after the statement date. These claims will appear on the next statement.
Member Number: 68600048552 Statement Date: 31/07/2012 Page 2

Claims Processed and Paid to the Healthcare Professional (HCP)

Amount Amount
HCP Treatment Tariff Amount Tariff Paid to Owing by Owing to Savings Reason
Claim Number Number HCP Name/Description Date Beneficiary Code* Charged Amount HCP Member Member Amount Codes**
EDI8126977073 6061338 Hyper-Pharm Moreletta Park 09/07/2012 00 John 862452007 253.43 253.43 253.43 0.00 0.00 253.43 505
09/07/2012 00 John 710870001 85.33 85.33 85.33 0.00 0.00 85.33 505
09/07/2012 00 John 847283003 36.23 33.45 33.45 0.00 0.00 33.45 387/504/535
Total 0.00 0.00
Balance due to you 0.00

Tariff Code Description*

Tariff Code Tariff Code Description
710870001 MICHOL
847283003 DISPRIN CV
862452007 CELEBREX

Reason Code Description**

Code Reason Code Description
387 Claim amount reduced according to the list of medicines approved by the scheme.
504 Claim line partially paid from savings/bonus account/Roll-over for Namibia only.
505 Claim line fully paid from savings/roll-over benefit.
535 Claimed amount has been reduced and paid at your scheme rate.

Savings Transactions
Claim / HCP Healthcare Capture Effective Savings
Transaction Nr Number Professional (HCP) / Description Date Date Amount
Opening Balance 01/07/2012 14978.59
EDI8126977073 6061338 Hyper-Pharm Moreletta Park 30/06/2012 30/06/2012 -372.21
68885521 Contribution Savings 01/07/2012 01/07/2012 639.00
Closing Balance 31/07/2012 15245.38
Savings Advance for the period 01/07/2012 to 30/09/2012: 1278.00
Total Savings Available as at 31/07/2012: 16523.38
Member Number: 68600048552 Statement Date: 31/07/2012 Page 3

Member Contributions
Transaction Date Effective Date Transaction Detail Amount
Opening Balance b/f 0.00
23/07/2012 01/08/2012 Contribution 2556.00
27/07/2012 01/08/2012 ACB Transaction -2556.00
120+ Days 90 Days 60 Days 30 Days Current Total
0.00 0.00 0.00 0.00 0.00 0.00
Contribution Tax Amount (2012/3) 12780.00
For direct deposits please use the scheme's bank account: Nedcor, Branch 195005, Account Number 1969125969

Important Message
Dear member, please be advised that your first point of contact for ALL medical emergencies requiring ambulance services and inter-hospital transfers must be through Europ Assistance on 086 100 6337.
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Please take note of the Scheme's Fraud Hotline number 0800 02 0800 to be contacted in the event of suspected fraud.
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The Medical Schemes Act requires Medshield to obtain ID numbers for all beneficiaries registered. It is crucial that the Scheme complies with the law. Please contact the Medshield contact centre on 086 000 2120 to provide
us with the details to update your records.
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Please be informed that you will be required to pay cash at any MediClinic hospital for any outpatient treatment received after 1 August 2010, without being admitted. Kindly submit your claims to Medshield for processing in
accordance with Scheme Rules and benefit availability.
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As of 1 May 2012 Medshield Medical Scheme's HIV/AIDS benefit management will be provided by LifeSense Disease Management. LifeSense will take over from Aid for Aids (AfA).