Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694853839018.pdf (Antigua and Barbuda)
MEDICAL BENEFITS SCHEME SMART CARD REPLACEMENT FORM Name of Beneficiary: _______________________ Date: ___________________ Smart Card#: ______________________________ Telephone: ______________________ Old Medical Benefits#: ________________________ Social Security: _____________________ Address: _________________________________________________________________________ Reason for Replacement: Lost Damaged Stolen Other_________________ REPLACEMENT FEE: EC $75.00 * N.B: The fee of EC $75.00 must first be paid to the cashier before replacement card can be processed CERTIFICATION I ________________________________certify that the original Smart Card issued to me by the Medical Benefits Scheme was _______________________________as indicated above.
Signature of Applicant: ________________________________ Date: ____________________ OFFICIAL USE RECOMMENDATION ______________________________________________________________________________ ______________________________________________________________________________ Registration Clerk: __________________________________ Date: _______________________ Approved: Yes No Comments: _______________________________________________________________________ Registration Supervisor: _________________________ Date: _____________________________ Production Clerk: _______________________________ Date: _____________________________