1. PERSONAL DETAILS
2. CONTACT DETAILS
3. BANKING DETAILS
I/We declare the Banking Details below are correct and authorize that they be used by the medical schemes and their
administrators for reimbursement of claims.
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I/We, the undersigned, hereby declare that the information contained on the application form is correct and duly
authorise the Association of Healthcare Funders of Zimbabwe (AHFoZ) to disseminate relevant information to its member societies.
I/We undertake to advise AHFoZ of any changes to my/our practice profile in the event that such changes may occur. I/We further declare that I/We will abide by the rules governing the Provider Numbers.
I/We acknowledge that any activities associated with fraud, waste and abuse will attract disciplinary measures as set out in the rules governing Provider Payee Numbers.