eForms

CHAS Patient Consent Form (applicable to both GP and Dentist):

On the patient’s first visit, the practitioner must obtain the patient’s consent to submit his clinical data and financial bill size for both acute and chronic consultations to MOH through the polyclinics. Such consent should be obtained using the provided CHAS Patient Consent Form (Medical or Dental). This form should be filed with the patient’s clinical notes which will be audited.

CHAS Patient Consent Form (Medical) in English

CHAS Patient Consent Form (Medical) in Mandarin

CHAS Patient Consent Form (Medical) in Malay

CHAS Patient Consent Form (Medical) in Tamil

CHAS Patient Consent Form (Dental) in English

CHAS Patient Consent Form (Dental) in Mandarin

CHAS Patient Consent Form (Dental) in Malay

CHAS Patient Consent Form (Dental) in Tamil

Other Forms

CHAS Cover Note for subsidised specialist outpatient care at Restructured Hospital (applicable to both GP and Dentist):

Practitioners participating in CHAS can refer their CHAS patients for subsidised specialist outpatient care at Restructured Hospitals. The referrals can be made even for conditions not covered under CHAS.

Practitioners must complete the form “CHAS Cover Note for subsidised specialist outpatient care at Restructured Hospital” and attach it with their referral letter and any additional documents on the patient’s medical/dental condition that are relevant for the referral. Practitioners must not specify the name of the specialist at the Restructured Hospital on the referral.

For specialist dental services, please refer CHAS patient to National Dental Centre (NDC) only.

CHAS Cover Note for subsidised specialist outpatient care at Restructured Hospital

Functional Assessment Report

For application of CHAS, a disabled patient will need to undergo a disability assessment after he passes the means test. He can choose to either approach his regular doctor to complete the Functional Assessment Report or to have the assessment done by a GP who is on the preferred list of General Practitioners. He will bear the cost of the disability assessment as part of the application process. The Functional Assessment Report has to be mailed to AIC at P.O. Box 680 Bukit Merah Central Post Office, Singapore 911536.

Functional Assessment Report

CHAS Application form and Consent/Declaration section (applicable to both GP and Dentist):

Practitioners who wish to provide CHAS application forms to their needy patients may print the CHAS Application form and the Consent/Declaration section (which comes in different languages; when necessary). Alternatively, practitioners may call AIC at 6632 1199 to request for the CHAS application forms and brochures to be delivered to the clinic.

CHAS Application Form

CHAS Application Form (Consent/Declaration section in Chinese/Malay/Tamil)