Forms
Click on an application form's name to download or display a printable PDF of the form.
Application forms
For new members – joining the scheme
- Application to join LA Health Medical Scheme 2020
- Application to join LA Health Medical Scheme 2019
- Application to join LA Health Medical Scheme – with underwriting 2020
- Application to join LA Health Medical Scheme – with underwriting 2019
For current members – adding or changing members
- Application to add dependant
- Application for registration of a newborn baby
- Continuation form (changing the main member)
For current members – managing benefits
- Additional benefits form
- Additional Health Benefits application form
- Advanced Illness Benefit application form
- Application for out-of-hospital management of a Prescribed Minimum Benefit condition
- Application for additional out-of-hospital treatment over and above PMB
- Broker appointment form
- Chronic Illness Benefit Application form
- Chronic Illness Benefit – Request for extended supply of medicine
- HIVCare Programme application form
- HIV Prescribed Minimum Benefit appeal form
- KeyPlus application for chronic dialysis
- Prescribed Minimum Benefits (PMB) Chronic Disease List (CDL) appeal form
- Request for pre-exposure prophylaxis
- Reverse claims form
For current members – managing membership
- External Medical Items Extender Benefit application Form
- International Travel Benefit Form
- Member Withdrawal Form
- Option Change Form
- Partnership Declaration Form
- Permission to change banking details
- Permission to make certain information available to a third party
- Pre-Assessment Request form
- Settlement agreement form
- Special payments from Medical Savings Account
- Transfer from active to retiree status
Benefit guides
- Advanced Illness Benefit
- Banking details for manual payments
- Chronic Illness Benefit CDL medicine list
- Compassionate Care Benefit
- Dental Benefit
- Diabetes Programme
- Disputes Process
- Emergency services
- Endoscopy services
- Guide to transplant claims submissions
- Guide to Prescribed Minimum Benefits
- HIV antiretroviral (ARV) medicine list
- HIV Basket of Care
- HIV Nutritional and mother-to-child medicine list (formulary)
- HIV supportive medicine list
- HIVCare Programme
- LA Focus hospital network
- LA KeyPlus Acute medicine list (formulary)
- LA KeyPlus Dental medicine list (formulary)
- LA KeyPlus hospital network
- Maternity Benefit
- Mental Health
- Menopause medicine list (formulary)
- Motor Vehicle Accident
- Oncology Innovation Benefit
- Oncology Programme
- Optical Benefit
- Out of Hospital Prescribed Minimum Benefits
- CIB CDL Treatment Basket
- Screening and Prevention Benefit
- Trauma Recovery Extender Benefit