Your Bridge To Premier Health Care
Principal Member Form
Fields marked with asterisks (
*
) are required.
Personal Information
Job Information
Identification & Plan Selection
Add Dependant(s)
Check Out
*
Surname
*
First Name
Other Names
*
Date Of Birth
*
Gender
Please Select
Male
Female
*
Contact Phone Number
Phone Number #2
*
Add Passport Size Picture
Next
*
Institution
Please Select Institution..
GHANA MEDICAL ASSOCIATION
PREMIER CARE
*
Staff ID
*
Email
*
Name Of Medical Facility
*
Region
Please Select Region..
Ahafo Region
Ashanti Region
Bono Region
Bono East Region
Central Region
Eastern Region
Greater Accra Region
Northern Region
North East Region
Oti Region
Savannah Region
Upper East Region
Upper West Region
Volta Region
Western Region
Western North Region
*
Municipality / District *
Please Select District.....
*
Town / Suburb *
*
Digital / Residential Address
Postal Address
Mode Of Payment
Please Select
Controller & Accountant General
Mobile Money
Visa Card
Master Card
Mandate Number
Mandate Pin
Select Platform
Please Select
MTN Mobile Money
Vodafone Cash
AirtelTigo Money
G-Money
Zeepay
Wallet Name
Wallet Number
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Plan Name
Premium
Platinum Plus
GH¢ 290.04
Platinum
GH¢ 204.60
Mercury
GH¢ 171.60
Regular
GH¢ 120.00
NHIS Number
*
Valid National ID
Please Select National ID.....
PASSPORT
DRIVERS LICENSE
SSNIT
VOTER'S ID
GHANA CARD
*
National ID Number
National ID Picture
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