Forms
Editable application forms are now available for you to complete digitally. You can navigate through the form by pressing the down arrow. If you can't physically sign a form, you must sign it digitally. We accept digital signatures from these digital signature providers:
- SigniFlow
- DocuSign
- Quickly Sign
- Hellosign
- Santamflow
- Smart Advice signatures
- Adobe Sign with certificate
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 2024
Application to join LA Health Medical Scheme
Application to join LA Health Medical Scheme - with underwriting
For current members - adding or changing members
Application for registration of a newborn baby
Continuation form (changing the main member)
For new members - joining the scheme 2023
Application to join LA Health Medical Scheme
Application to join LA Health Medical Scheme - with underwriting
For current members - adding or changing members
Application for registration of a newborn baby
Continuation form (changing the main member)
For current members - managing benefits
Home Care Service Provider application 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
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
For current members - managing membership
External Medical Items Extender Benefit application Form
International Travel Benefit Form
Permission to change banking details
Permission to make certain information available to a third party
Special payments from Medical Savings Account
Transfer from active to retiree status
Benefit guides
Assisted Reproductive Therapy Benefit - LA COMPREHENSIVE
Guide to prescribed minimum benefits for in-hospital treatment
Banking details for manual payments
Chronic Illness Benefit medicine list (Provisional Formulary)
Chronic Illness Benefit CDL medicine list
Guide to transplant claims submissions
Guide to Prescribed Minimum Benefits
HIV antiretroviral (ARV) medicine list
HIV Nutritional and mother-to-child medicine list (formulary)
LA KeyPlus Acute medicine list (formulary)
LA KeyPlus Dental medicine list (formulary)
Menopause medicine list formulary
Oncology Supportive Medicine List Formulary
Screening and Prevention Benefit
Spinal Conservative Care Programme