1.Medisave Authorisation Form for Chronic Diseases

Click here to download the form. The Medisave Account Holder and/or patient are to complete the form at home, sign the document and bring the completed form to our Financial Counsellors at the polyclinic during the next visit.

 

2.Medisave Authorisation Form for Outpatient Treatment

Click here to download the form. The Medisave Account Holder and/or patient are to complete the form at home, sign the document and bring the completed form to our polyclinic during the next visit. Our Patient Service Associates (PSAs) can help to process your Medisave (Outpatient) application at the point of payment at the end of your visit.

 

Important notes for Medisave Application Forms:

Please ensure that you have completed the following COMPULSORY items in the Medisave Application Forms and/or taken the necessary actions before visiting our polyclinics.

  • Please complete all fields in Part I: Particulars of Patient
  • Please complete all fields in Part II: Particulars of Medisave Account Holder
  • Please tick one of the box to indicate the period over which the Medisave Account Holder wishes to authorise NHGP to deduct their Medisave Account in Part III: Purpose of Withdrawal
  • Part IV & V: Authorisation & Declaration By Medisave Account Holder & Patient

Signature of Medisave Account Holder and Patient

Name and NRIC number of witness*, followed by witness’s signature

It is compulsory to submit a photocopy of the Medisave Account Holder’s NRIC to our staff during the process of your application. We will not be able to process your application if this document is not given to our staff at the clinic.

Please ensure that all the necessary fields are completed and/or counter-signed by the Medisave Account Holder. We seek your understanding that any incomplete form or any alteration without being countersigned by the Medisave Account Holder will NOT be processed.

*Witness has to be a third person, not the patient nor the Medisave Account Holder and must be a Singaporean 21 years old and above, and of sound mind