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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 to add dependant

  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 to add dependant

  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

  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

  Application to transfer an existing member to another employer group or another branch of the existing employer group

  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

  Assisted Reproductive Therapy Benefit - LA COMPREHENSIVE

  LA Health Online Guide

  Guide to prescribed minimum benefits for in-hospital treatment

  Advanced Illness Benefit

  Banking details for manual payments

  Chronic Illness Benefit medicine list (Provisional Formulary)

  Chronic Illness Benefit CDL medicine list

  Compassionate Care Benefit

  Coronary Sents

  COVID-19 Recovery Booklet

  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 KeyPlus Acute medicine list (formulary)

  LA KeyPlus Dental medicine list (formulary)

  Menopause medicine list formulary

  Maternity Benefit

  Mental Health

  Motor Vehicle Accident

  Oncology Innovation Benefit

  Oncology Programme

  Oncology Supportive Medicine List Formulary

  Optical Benefit

  CIB CDL Treatment Basket

  Screening and Prevention Benefit

  Spinal Conservative Care Programme

  Trauma Recovery Extender Benefit

  Underwriting guidelines

  WELLTH Fund Benefit

  WHO global outbreak benefit

  Prescribed minimum benefit WHO basket

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