Discovery Health Practice Registration Form 2026 (DHHPR2001) Instructions

Please enter the full name of the bank where the account is held.

Please enter the name of the branch where the bank account is registered.

Please enter the first segment of the bank branch code.

Please enter the second segment of the bank branch code.

Please enter the third segment of the bank branch code.

Please enter the full bank account number.

Please enter the full name of the bank account holder.

Enter the healthcare professional's or practice owner's family name (surname).

Enter the healthcare professional's or practice owner's given name(s) as used officially.

Enter the professional's maiden surname if applicable, otherwise leave blank.

Enter the work telephone area or country code or the initial dialling digits for the work number.

Enter the remainder of the work telephone number (excluding the area/country code entered in the previous box).

Enter the cellphone country or area code or the initial dialling digits for the mobile number.

Enter the remainder of the cellphone/mobile number (excluding the code entered in the previous box).

Enter a valid email address for the healthcare professional or practice owner for contact purposes.

Enter the surname (family name) of the second contact, the healthcare professional or practice owner.

Enter the given name(s) of the second contact, the healthcare professional or practice owner.

Enter the maiden surname of the second contact if applicable, otherwise leave blank.

Enter the area code or prefix portion of the second contact's work telephone number.

Enter the local portion of the second contact's work telephone number.

Enter the area code or prefix portion of the second contact's cellphone number.

Enter the local portion of the second contact's cellphone number.

Enter the email address for the second contact, the healthcare professional or practice owner.

Enter the surname/family name of the third healthcare professional or practice owner.

Enter the given name(s) (first name and any middle names) of the third healthcare professional or practice owner.

If applicable, enter the maiden or former surname of the third healthcare professional or practice owner; otherwise leave blank.

Enter the work telephone area code or prefix (the initial segment) for the third contact's daytime phone number.

Enter the remainder of the third contact's work telephone number excluding the area/prefix.

Enter the cellphone area code or prefix (initial segment) for the third contact's mobile number.

Enter the remainder of the third contact's mobile phone number excluding the area/prefix.

Enter the email address for the third healthcare professional or practice owner.

Enter the family/surname of the fourth healthcare professional or practice owner.

Enter the given name(s) (first and middle names) of the fourth healthcare professional or practice owner.

Enter the maiden (birth) surname of the fourth healthcare professional if different from the current surname, or leave blank if not applicable.

Enter the area or STD/country code for the fourth contact's work telephone number.

Enter the local part of the fourth contact's work telephone number (excluding the area/code).

Enter the country or area code for the fourth contact's mobile (cell) phone.

Enter the local part of the fourth contact's mobile phone number (excluding the country/area code).

Enter the email address for the fourth healthcare professional or practice owner.

Enter the full name of the contact person.

Enter the first part of the contact person's home telephone number.

Enter the second part of the contact person's home telephone number.

Enter the first part of the contact person's work telephone number.

Enter the second part of the contact person's work telephone number.

Enter the first part of the contact person's cellphone number.

Enter the second part of the contact person's cellphone number.

Enter the contact person's email address.

Check this box if you are registering a single practitioner practice (an individual practice).

Check this box if you are registering a practice made up of multiple healthcare professionals linked as a group practice.

Check this box if you are registering a practice that is a legally incorporated entity (an incorporated practice).

Check this box if your postal address is a PO Box, and then enter the PO Box number in the 'Box number' field.

Check this box if your postal address is a Private Bag, and then enter the bag number in the 'Box number' field.

Check this box if your postal address is a Suite (post collected from a suite), and then enter the suite number in the 'Number' field.

Check this box if your postal address is a Postnet Suite, and then enter the suite number in the 'Number' field.

Check this box if the provided banking account is a cheque account.

Check this box if the provided banking account is a savings account.

Check this box if the banking details apply to the Premier Plus monthly fee.

Check this box if the banking details apply to normal claims.

Check this box if the banking details apply to both the Premier Plus monthly fee and normal claims.

Please provide the full name of the undersigned individual.

Please enter the town or city where this document was signed.

Please enter the date on which this document was signed.

Enter the person's surname.

Enter the person's given name.

Enter the person's maiden surname, if applicable.

Enter the first part of the person's work telephone number.

Enter the second part of the person's work telephone number.

Enter the first part of the person's cellphone number.

Enter the second part of the person's cellphone number.

Enter the person's email address.

Enter the BHF personal practice number assigned to this individual practice as shown on BHF documentation. Fill only if 'Group practice' is 'Yes'.

Enter the practitioner's South African ID number for the individual linked to this practice. Fill only if 'Group practice' is 'Yes'.

Enter the practice's VAT registration number (if applicable) exactly as it appears on the VAT registration document. Fill only if 'Group practice' is 'Yes'.

Enter the BHF personal practice number assigned to this practice for Practice Entry 2. Fill only if 'Group practice' is 'Yes'.

Enter the individual or practice ID number (e.g., national ID or company ID) associated with Practice Entry 2. Fill only if 'Group practice' is 'Yes'.

Enter the VAT registration number for this practice as it applies to Practice Entry 2. Fill only if 'Group practice' is 'Yes'.

Enter the practice's BHF client or personal practice number assigned by Discovery Health for this practice. Fill only if 'Group practice' is 'Yes'.

Enter the official identification number for the practice (for example company registration number or the principal practitioner's national ID) associated with this practice. Fill only if 'Group practice' is 'Yes'.

Enter the practice's VAT registration number as recorded with the tax authorities. Fill only if 'Group practice' is 'Yes'.

Enter the BHF client or practice number assigned to this practice for Practice Entry 4. Fill only if 'Group practice' is 'Yes'.

Enter the primary official ID number (national identity number) for the practice signatory or practice registration for Practice Entry 4. Fill only if 'Group practice' is 'Yes'.

Enter the VAT registration number associated with this practice for Practice Entry 4. Fill only if 'Group practice' is 'Yes'.

Enter the BHF (personal practice) number assigned to this practitioner or practice as shown on BHF documentation. Fill only if 'Group practice' is 'Yes'.

Enter the practitioner's national ID number associated with this practice entry. Fill only if 'Group practice' is 'Yes'.

Enter the VAT registration number for the practice if applicable. Fill only if 'Group practice' is 'Yes'.

Enter the BHF (Discovery Health) personal practice number assigned to this practitioner for Practice Entry 6. Fill only if 'Group practice' is 'Yes'.

Enter the practitioner's national ID number associated with Practice Entry 6. Fill only if 'Group practice' is 'Yes'.

Enter the practice's VAT registration number for Practice Entry 6, if applicable. Fill only if 'Group practice' is 'Yes'.

Enter the practice's BHF personal practice number exactly as assigned by Discovery Health or the BHF, including any leading zeros or punctuation shown on official documents. Fill only if 'Group practice' is 'Yes'.

Enter the practitioner's official identification number (for example South African ID or passport number) exactly as it appears on the ID document. Fill only if 'Group practice' is 'Yes'.

Enter the practice's VAT registration number exactly as registered with SARS, including any letters, numbers or check digits shown on the VAT certificate. Fill only if 'Group practice' is 'Yes'.

Enter the full official name of the practice exactly as it should appear on Discovery Health records and correspondence.

Enter the official/legal name of the practice as registered.

Enter the practice's trading or 'doing business as' (DBA) name if different from the legal name; leave blank if same.

Enter the practice's registration, license, or identification number issued by the relevant authority.

Enter the practice's primary telephone number, including area code and any extension if applicable.

Enter the practice's fax number, including area code, or leave blank if not applicable.

Enter the main email address used for practice correspondence and official communications.

Enter the practice's website address or URL, if available.

Enter the full name of the main contact person for the practice (for example, practice manager).

Enter the telephone number for the primary contact, including area code and extension if needed.

Enter the unique practice number assigned to this practice by Discovery Health (provide the official numeric identifier for the practice).

Enter the practice office telephone country or area code (if applicable), for example +64 or 09.

Enter the practice office local telephone number excluding the country/area code.

Enter the cellphone country or area code (if applicable), for example +64.

Enter the rest of the cellphone number excluding the country/area code.

Enter the practice office email address used for official correspondence.

Enter the unit or suite number for the practice's physical address (if applicable).

Enter the name of the building complex, estate, or property where the practice is located (if applicable).

Enter the street or building number for the practice's physical address.

Enter the full street name for the practice's physical address (e.g., Main Street).

Enter the city, town, or suburb where the practice is located.

Enter the postal or ZIP code for the practice's physical address.

Enter the box number used for the practice's postal delivery (for example a PO Box, private bag or suite box number). Fill only if 'PO Box', 'Private Bag' is 'Yes' (any).

Enter the secondary postal number associated with the selected postal delivery option (for example a postnet suite or private bag number). Fill only if 'Suite', 'Postnet Suite' is 'Yes' (any).

Enter the suburb or locality for the practice's postal address. Fill only if 'PO Box', 'Private Bag', 'Suite', 'Postnet Suite' is 'Yes' (any).

Enter the city or town for the practice's postal address. Fill only if 'PO Box', 'Private Bag', 'Suite', 'Postnet Suite' is 'Yes' (any).

Enter the postal code for the practice's postal address. Fill only if 'PO Box', 'Private Bag', 'Suite', 'Postnet Suite' is 'Yes' (any).

Please enter the identification or passport number for the individual or entity.

Please enter the company's registration number.

Check this box if the account is registered with a person's identity number (ID).

Check this box if the account is registered with a company registration number.

Please enter the town or city where the document was signed.

Please enter the date when the document was signed.