Annexure A: Prescribed Form to Be Completed by a Requester

Form – Request for Access to Records Held by CompCare Medical Scheme

(In Terms of Section 53 (1) of the Promotion of Information Act, No 2 of 2000 [regulation 10]):

Particulars of CompCare Medical Scheme

The Information Officer
CompCare Medical Scheme
P O Box 1411
RIVONIA
2128

Particulars of Person Requesting Access to the Record

a. The particulars of the person who requests access to the Records must be recorded below.
b. Furnish an address and/or fax number in the republic to which information must be sent.
c. Proof of the capacity in which the request is made, if applicable, must be attached.

Full Names and Surname:(Required)

First Last

Identity Number:(Required)

Postal Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Number:(Required)

Fax Number:

E-mail Address:(Required)

Are You Completing This Request on Another Person's Behalf?(Required)

Yes

Full Names and Surname:(Required)

First Last

Identity Number:(Required)

Capacity in Which the Request is Made, When on Behalf of Another Person:(Required)

Particulars of Record

a. Provide full particulars of the record to which access is requested including the reference number that is known to you, to enable the record to be located.
b. If the provided space is inadequate, please continue on a separate page and attach it to this form. The requestor much sign all the additional pages.

Description of the Record or Relevant Part of the Record:(Required)

Reference Number (if Applicable):

Any Further Particulars of the Record:

Fees

a) A request for access to a record, other than a record containing personal information about yourself, will be processed only after a request fee has been paid.
b) You will be notified of the amount of the request fee.
c) The fee payable for access to a record depends on the form in which the access is required and the reasonable time required to search for and prepare a record.
d) If you qualify for exemption of the payment of any fee, please state the reason therefore below:

Reason for Exemption of Payment of the Fee:

Form of Access to the Record

If you are prevented by a disability to read, view or listen to the record in the form of access provided for in 1 to 4 below, state your disability and indicate in which form the record is required.

Disability:

Form in Which the Record is Required:(Required)

Please note:

a) Your indication as to the required form of access depends on the form in which the record is available.
b) Access to the form requested may be refused in certain circumstances. In such cases, you will be informed if access could be granted in another form.
c) The fee payable for access to the record, if any, will be determined by the form in which access is requested.

Please select the appropriate box:

1. If the record is in written form:(Required)

2. If the record consists of visual images (this includes photographs, slides, video recordings, computer generated images, sketches etc.):(Required)

3. If the record consists of recorded words or information which can be produced by sound:(Required)

4. If the record is held on a computer or in an electronic or machine-readable form:(Required)

If you requested a copy or transcription of a record (above), do you wish the copy or transcription to be posted to you?(Required)

Yes

*Note: a postal fee is payable.

Particulars of Right to be Exercised or Protected

1. Indicate which right is to be exercised or protected:(Required)

2. Explain why the requested record is required for the exercising or protection of the aforementioned right:(Required)

Notice of Decision Regarding Request for Access

You will be notified in writing whether your request has been approved/denied. If you wish to be informed thereof in another manner, please specify and provide the necessary particulars to enable compliance with your request.

How would you prefer to be informed of the decision regarding your request for access to the record?(Required)

Signed at:(Required)

Date of Signature:(Required)

MM slash DD slash YYYY

Consent of Requester/Person on Whose Behalf the Request is Made(Required)

I agree to making a request for access to records held by CompCare Medical Scheme.

For Internal Use Only

Reference Number:

Request Received By:

(Name of Information Officer/Deputy Information Officer)

First Last

Request Approved or Declined:

Approved

Declined

Letter Sent On:

MM slash DD slash YYYY

Fees Payable

Request Fee (if Any):

Deposit (if Any):

Access Fee:

Total Fees Payable:

Confirmation of Fees Paid:

Consent of Information Officer/Deputy Information Officer

I agree to the fees listed above.

Phone

This field is for validation purposes and should be left unchanged.

Annexure A: Prescribed Form to Be Completed by a Requester

Form – Request for Access to Records Held by CompCare Medical Scheme

Particulars of CompCare Medical Scheme

Particulars of Person Requesting Access to the Record

Particulars of Record

Fees

Form of Access to the Record

Please note:

Particulars of Right to be Exercised or Protected

Notice of Decision Regarding Request for Access

For Internal Use Only

Fees Payable

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