Social Assistance Act, 2004 (Act No. 13 of 2004)

Regulations

Regulations relating to the Lodging and Consideration of Applications for Reconsideration of Social Assistance Application by the Agency and Social Assistance Appeals by the Independent Tribunal

Annexure A : Consolidated Forms

Form 6 : Referral Form for Second Medical Examination or Opinion
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FORM 6

 

REFERRAL FORM FOR SECOND MEDICAL EXAMINATION OR OPINION

(Regulation 18(4))

 

A.        PERSONAL DETAILS OF APPLICANT OR BENEFICIARY

Surname:

Full Names:

ID Number:

Nationality:

Gender:       M

F

Tel No:

Fax No:

Email:

Cell No:

Physical Address

Postal Address

 

B.        DETAILS OF GRANT APPLICATION AND APPLICATION FOR RECONSIDERATION

Agency Office:

Date of Application:

 

Date of Rejection:

 

Date of Application For Reconsideration:

Date of Rejection of Application for reconsideration

Type of Grant (Mark with "X")

Disability

Older

Persons'

War

Veteran

Foster

Child

Care

Dependency

Child

Support

Grant in

Aid

Social

Relief

of

Distress

 

C.        REFERRAL

 

In accordance with regulation 18, the above mentioned applicant or beneficiary is hereby referred for a second and independent medical examination or opinion as follows:

Date of Medical Examination:

Time:

Telephone Number:

 

Venue:

Physical Address:

Name of medical practitioner:

 

D.        SECOND MEDICAL EXAMINATION OR OPINION

EXISTENCE OF DISABILITY:

Is disability certified?

Yes

No

NATURE OF DISABILITY












 

 

 

Medical Doctor's signature and stamp