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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

  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

  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

  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

  Motor Vehicle Accident

  Oncology Innovation Benefit

  Oncology Programme

  Optical Benefit

  CIB CDL Treatment Basket

  Screening and Prevention Benefit

  Trauma Recovery Extender Benefit

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