Application For CHAS / Higher Healthcare Subsidies: Benefits

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Application for CHAS /


Higher Healthcare Subsidies
Benefits By submitting this form1, households are applying for:

• Subsidies at participating CHAS GP and dental clinics, with their CHAS cards
• Higher healthcare subsidies at public specialist outpatient clinics (SOCs) and polyclinics

Eligibility All Singapore Citizens2 are eligible for CHAS. Lower- to middle-income
households3 receive higher healthcare subsidies. Benefits are tiered by:
• Household monthly income per person4 (for households with income)
• Annual Value (AV)5 of home as reflected on the NRIC (for households with no income)

Visit www.chas.sg/apply to apply online from Sep 2019 onwards.


Apply
Alternatively, you may submit this hardcopy application form by following
Online
the steps below.

Step 1: Complete a combined application on behalf of all your Family Members sharing
Complete the same NRIC address. Please include all Family Members sharing the same
Form address in this form.

Step 2: Only the Main Applicant is required to sign the form on behalf of your Family
Sign Members. Please ensure that you have informed all Family Members of the
Form application and obtained the agreement required in the form.

Step 3:
Send the completed form6 to Bukit Merah Central Post Office, P.O. Box 680,
Submit
Singapore 911536.
Form

1 Please note that you and your Family Members will be assessed for eligibility for CHAS and higher healthcare subsidies based on income and other
personal information available in government databases. The information provided in this form may result in an update to you and/or your household
members’ eligibility for other government healthcare schemes, such as subsidies for MediShield Life Premiums, disability schemes etc.
2 Singapore Citizens who are on the Public Assistance (PA) scheme do not need to apply.
3 Please refer to the MOH website (www.moh.gov.sg) for the prevailing eligibility criteria for higher healthcare subsidies.
4 Household monthly income per person is the total gross household monthly income divided by total number of family members sharing the same
address (as reflected on the NRIC or Birth Certificate). Gross household monthly income refers to your basic employment income,
trade/self-employed income, overtime pay, allowances, cash awards, commissions, and bonuses.
5 The AV of your home is the estimated annual rent if it is rented out. It is assessed by IRAS.
6 Incomplete forms lacking signatures/thumbprints or contact details will be sent back to the applicants for completion.

Visit www.chas.sg or call 1800-275-2427 for more information


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Particulars of Main Applicant
1 Name (in BLOCK LETTERS, as in NRIC)

Pink NRIC / Birth Certificate number (Main Applicant must be a Singapore Citizen)

Mailing Address (if different from NRIC)

Home number Mobile number^ Notification Preference^


SMS and Mail Mail Only

Dwelling Type (based on NRIC address)


HDB Flat Private Housing Institution (MOH/MSF Others: _________________
(incl. Executive Condo) licensed home) (please specify)

Rental Status of Residence

Renting from Government Renting from open market Not rented (e.g. bought or owned)

Particulars of Family Members sharing the same NRIC address


2 Name (in BLOCK LETTERS, as in NRIC)

Pink NRIC / Blue NRIC / Birth Certificate / FIN Mobile number^


(Please circle the above and fill in your identification number below)

Relationship to Main Applicant (e.g. spouse, child, parent, etc) Notification Preference^

SMS and Mail Mail Only

3 Name (in BLOCK LETTERS, as in NRIC)

Pink NRIC / Blue NRIC / Birth Certificate / FIN Mobile number^


(Please circle the above and fill in your identification number below)

Relationship to Main Applicant (e.g. spouse, child, parent, etc) Notification Preference^

SMS and Mail Mail Only

^ By selecting ‘SMS and Mail’ as your notification preference, you have agreed to be contacted and will receive notifications at the provided mobile number, in
addition to correspondence by mail.

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July 2019
Particulars of Family Members sharing the same NRIC address
4 Name (in BLOCK LETTERS, as in NRIC)

Pink NRIC / Blue NRIC / Birth Certificate / FIN Mobile number^


(Please circle the above and fill in your identification number below)

Relationship to Main Applicant (e.g. spouse, child, parent, etc) Notification Preference^

SMS and Mail Mail Only

5 Name (in BLOCK LETTERS, as in NRIC)

Pink NRIC / Blue NRIC / Birth Certificate / FIN Mobile number^


(Please circle the above and fill in your identification number below)

Relationship to Main Applicant (e.g. spouse, child, parent, etc) Notification Preference^

SMS and Mail Mail Only

6 Name (in BLOCK LETTERS, as in NRIC)

Pink NRIC / Blue NRIC / Birth Certificate / FIN Mobile number^


(Please circle the above and fill in your identification number below)

Relationship to Main Applicant (e.g. spouse, child, parent, etc) Notification Preference^

SMS and Mail Mail Only

7 Name (in BLOCK LETTERS, as in NRIC)

Pink NRIC / Blue NRIC / Birth Certificate / FIN Mobile number^


(Please circle the above and fill in your identification number below)

Relationship to Main Applicant (e.g. spouse, child, parent, etc) Notification Preference^

SMS and Mail Mail Only

^ By selecting ‘SMS and Mail’ as your notification preference, you have agreed to be contacted and will receive notifications at the provided mobile number, in
addition to correspondence by mail.

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July 2019
Consent/Declaration
Definitions

1. Throughout this form, the words and expressions below shall have the meanings hereby ascribed to them.

2.1 “Cooperating Parties” shall refer to the Government of the Republic of Singapore (the “Government”), and such statutory boards and
organisations as approved by the Government that are involved in or assisting in the provision and delivery of the Services and
Schemes.

2.2 “Family Member” means a person related to the Main Applicant by blood, marriage and/or legal adoption.

2.3 “Personal Information” means an individual’s personal data (e.g. name, NRIC No., address, age, gender, family/household structure),
financial data (e.g. income, savings, insurance coverage), consumption data (e.g. payment for utilities, housing, healthcare bills, scheme
participation), social assistance data (e.g. social assistance history, assessments for eligibility and suitability for various Services and
Schemes, social worker case reports) or medical information, that is relevant for the Purpose (as defined in paragraph 4 below).

2.4 “Services and Schemes” means public services and schemes, which include the following:
(a) healthcare, aged care, childcare, education, social assistance and counselling services and schemes;
(b) any form of financial assistance such as subsidies, grants, tax reliefs, vouchers or bursaries; and
(c) retirement, savings and insurance schemes operated by Government, CPF Board and/or their appointed agents.

Consent

3. I understand that the sharing of Personal Information between different entities such as the Government, and certain statutory boards,
and organisations as approved by the Government will assist in the evaluation of my and/or my Family Members’ suitability and
eligibility for the Services and Schemes.

4. By signing this consent, I agree that any Cooperating Party may:


(a) collect my Personal Information from me or any of the other Cooperating Parties;
(b) disclose my Personal Information to any of the other Cooperating Parties; and
(c) use my Personal Information,
regardless of whether my Personal Information relates to matters occurring before, on or after the date of this consent, for the purposes
of:
(i) evaluating my and/or my Family Members’ suitability and eligibility for the Services and Schemes at any time;
(ii) the administration and provision of the Services and Schemes in relation to me and/or my Family Members; and/or
(iii) data analysis, evaluation and policy formulation, in which I and/or my family members shall not be identified as specific individuals
or households
(collectively known as the “Purpose”).

5. I consent to the Inland Revenue Authority of Singapore (“IRAS”) and the Central Provident Fund Board (“CPF Board”) disclosing to any
Cooperating Party the following information (hereinafter referred to as the “IRAS and CPF Information”):
(a) my income information;
(b) information relating to my CPF contributions and any information that may be derived therefrom;
(c) information relating to my CPF Accounts (e.g. account balance, withdrawal details, etc.);
(d) information relating to or arising from my participation in schemes administered by the CPF Board (e.g. medical information,
insurance coverage, etc.)
whether such IRAS and CPF Information relates to matters occurring before, on or after the date of this consent, necessary for the
purposes of means-testing or otherwise determining my and/or any of my Family Members’ access to or eligibility for any Services and
Schemes, as and when required from time to time. For the avoidance of doubt, the IRAS and CPF Information shall not include such
information obtained by CPF Board in the course of conducting surveys.

6. I understand that this consent shall remain in effect unless revoked in writing. I accept that the withdrawal of consent will only take effect
within 7 working days from the date of receipt of the withdrawal.

7. This consent shall be governed by and construed in accordance with the laws of the Republic of Singapore.

Declaration

8. I declare that I am the Main Applicant, or an individual authorised to provide consent on behalf of the Main Applicant (“Authorised
Individual”).

9. Where I am providing consent on behalf of the Main Applicant who is under 21 years of age, I further declare that I am his/her parent /
legal guardian.

10. Where I am providing consent on behalf of the Main Applicant who is mentally incapacitated, I further declare that I am:
(a) his/her appointed donee(s) acting under a Lasting Power of Attorney granted by the Main Applicant under the Mental Capacity Act
(Cap. 177A) when he/she was above 21 years old, or
(b) his/her deputy(s) appointed by the Court under the Mental Capacity Act (Cap. 177A) to act on behalf of the Main Applicant.

11. I declare that all the information provided by me in this form is true, correct and accurate.

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Consent/Declaration
12. I declare that I have informed each of my Family Members (or, where this declaration is made by an Authorised Individual, each of the
Family Members of the Main Applicant) listed in this Form about this application, and have obtained each of their agreement that any
Cooperating Party may:
(a) collect their Personal Information from me or any of the other Cooperating Parties;
(b) disclose their Personal Information to any of the other Cooperating Parties; and
(c) use their Personal Information,
regardless of whether their Personal Information relates to matters occurring before, on or after the date of this declaration, for the
purposes of:
(i) evaluating my and/or my Family Members’ (or, where this declaration is made by an Authorised Individual, the Main Applicant
and/or his/her Family Members’) suitability and eligibility for the Services and Schemes at any time;
(ii) the administration and provision of the Services and Schemes in relation to me and/or my Family Members (or, where this
declaration is made by an Authorised Individual, the Main Applicant and/or his/her Family Members); and/or
(iii) data analysis, evaluation and policy formulation, in which I and/or my Family Members (or, where this declaration is made by an
Authorised Individual, the Main Applicant and his/her Family Members) shall not be identified as specific individuals or households.

13. I understand and acknowledge that if any of the information provided by me in this form is false or inaccurate, I will be liable to repay in
full the value of any assistance granted, inclusive of all administrative expenses, and also may face criminal prosecution. I further
undertake to be liable for, and to indemnify the Government and all Cooperating Parties against, all losses, expenses, costs (including
legal costs calculated on a full indemnity basis), damages and liabilities that may be suffered or incurred by the Government and all
Cooperating Parties arising out of or in connection with my application in this form including but not limited to that arising out of or in
connection with claims from or by my Family Members in relation to this application.

Consent/Declaration by Main Applicant on Behalf of Family


Name of signatory
(Where consent is provided on behalf of
1 Main Applicant’s Name Signature/Thumbprint (Date): the Main Applicant)++:

I hereby confirm that I understand and


agree to all the provisions in this form.

++ Tick one of the following, where applicable: I am the parent / legal guardian and I/We have declared on behalf of the
have declared on behalf of the Main Main Applicant who is mentally
Applicant who is under 21 years of age. incapacitated.

Responsibilities of Main Applicant:


Please ensure that you have informed all Family Members about your application on their behalf, and obtained
their relevant agreement as required under the Form. Upon receipt of this application, a letter of
acknowledgement will be sent to the Main Applicant’s residential address (as reflected on his/her NRIC). Family
Members who have selected ‘SMS and Mail’ as their notification preference will also be individually notified of the
CHAS application through SMS.

Instructions:
1) Please provide a copy of the signatory’s NRIC/Passport if he/she is not the Main Applicant listed in this application. Note
that the signatory has to be the parent / legal guardian / donee / deputy.
2) Please check whether the donee/deputy may act singly or has to act jointly with other donee(s)/deputy(s). If the
donees/deputies are required to act jointly, all donees/deputies must provide consent on behalf of the Main Applicant /
Family Member. Please provide a copy of the Lasting Power of Attorney / Order of Court and NRIC/Passport of the
donee(s)/deputy(s) if he/she is not the Main Applicant / Family Member listed in this application.
3) If the Main Applicant is unable to provide consent, please complete the section “Main Applicant Unable to Provide
Consent or Consent on Behalf ” on Page 6.

If the above signatory does not read English, the name of the interpreter is ______________________________(name),

______________________________(NRIC), ______________________________(contact number).

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July 2019
Consent/Declaration

Main Applicant Unable to Provide Consent or Consent on Behalf

The following Main Applicant (aged 21 and above):


a) is unable to provide consent due to his/her mental incapacity, a donee has not been appointed to act for him
under a Lasting Power of Attorney, and a deputy has not been appointed to act for him by the Court under
the Mental Capacity Act (Cap. 177A); and
b) has no Family Members sharing the same NRIC address*
(please fill in doctor’s certification below).

Name (as in NRIC): ___________________________________________________


* This section should not be filled in by a Main Applicant who is mentally incapacitated but has an appointed donee/deputy.
The donee/deputy can give consent on behalf of the Main Applicant on Page 5, and a doctor’s certification is not required.
The section is also only for a Main Applicant with no Family Members sharing the same NRIC address.

Doctor’s Certification for Inability to Provide Consent due to Mental Incapacity

I certify that the above-named Main Applicant is:


Temporarily mentally incapacitated and is unable to provide consent
Permanently mentally incapacitated and is unable to provide consent

Official stamp of clinic/hospital

Name of doctor Signature of doctor

Date MCR number Contact number

Instructions:
• Date of doctor’s certification must be within 6 months from date of submitting this form unless the Main Applicant is
permanently mentally incapacitated.
• If the doctor is not able to certify and sign this form, a separate doctor’s memorandum indicating that the Main Applicant
is unable to provide consent/declaration due to the relevant medical reason may be attached.

For Official Use


This application is verified/processed by:

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July 2019

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