Learn on How to Claim First Name Last Name Date on which service was rendered Email Address Contact Number details of service provider and patient Practice location of the professional rendering the service - None -GaboroneFrancistownMolepololeSeroweSelebi PhikweMaunKanyeMahalapyeMogoditshaneMochudiLobatsePalapyeRamotswaMoshupaTlokwengBobonongThamagaLetlhakaneTonotaMmadinareJwanengTutumeGabaneShoshongGhanziLetlhakengOrapaMmopaneKasaneShakaweGumareTsabongGwetaNataTati SidingHukuntsiKangMasunga Number of the professional rendering the service Code number of Items/ recognised tariffs Copies of original documents should be certified by the supplier of the service e.g. prescriptions One file only.8 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Referrals Yes No Copy of referral letter The referral letter and presciption have a three month validity period. One file only.8 MB limit.Allowed types: jpg, pdf. Membership Number Attach Signed Invoices Make sure that the invoice is signed by yourselves. Also .... One file only.8 MB limit.Allowed types: jpg, pdf. Attach Receipts/Proofs of PaymenT One file only.8 MB limit.Allowed types: jpg, pdf. Name of benefit option CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.