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Application forms

For new members - joining the Scheme in 2025

Application to join LA Health Medical Scheme

For current members

Application for registration of a newborn

Application to add dependants

Continuation form

Chronic Illness Benefit application form 2025

Record of advice

Option Change Form

For current members - managing benefits

Advanced Illness Benefit application

Application for additional benefits

 Application for additional benefits

Application for additional out-of-hospital treatment over and above pmb

Application to add dependants (with underwriting)

Application to become a member (with underwriting)

Application for out-of-hospital management of a Prescribed Minimum Benefit condition

Application for registration of a new-born baby

Application for special payments made from the Medical Savings Account

Application to transfer an existing member to another employer or branch

Chronic Illness Benefit application form

Claim form for medical costs incurred outside SA

Claims reversal form

Continuation form

Extended supply of medicine

External Medical Items Extender Benefit Application (LA Comprehensive)

HIV PMB application

HIVCare programme application form

Membership/ dependant withdrawal form

Membership application form

New broker / brokerage appointment form

Option Change form

Partnership declaration

Pre-assessment request

Permission to make certain information available to a third party

Request for additional cover for Chronic Disease List (CDL) conditions registered on the Chronic Illness Benefit (CIB)

Request for extended supply of medicine

Request for pre-exposure prophylaxis (PREP)

Request to change banking details

Request to reverse the payment of a claim

Settlement agreement for an amount owing to LA Health Medical Scheme

Transfer from active to retiree status

Screening benefit exception form

Bariatric surgery application form

Declaration of medical scheme membership

Dyspepsia conservative care programme application form for high risk patients

Application to become a member (without underwriting)

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