KeyHealth Chronic Form

This form is required as part of the membership transfer process to capture details of any existing chronic conditions and chronic medication.

The information provided will be shared with KeyHealth Medical Scheme for notification and continuity of care purposes.

Please note that completing this form does not constitute formal chronic registration.

Once your KeyHealth membership has been activated, KeyHealth’s appointed chronic disease management provider, MediKredit, will contact you directly to guide you through and finalise the chronic registration process.

To avoid unnecessary delays once registration commences, please ensure that this form is completed in full and that all information provided is accurate and up to date.

Form for Completion

Section 1: Principal Member Details

Section 2: Dependant Details (if applicable)

Section 3: Chronic Conditions

Chronic condition 1

Chronic condition 2

Chronic condition 3

Additional Chronic Conditions

Declaration & Consent

Declaration

I confirm that the information provided in this form is true, accurate and complete to the best of my knowledge. I understand that this form is submitted for information-sharing purposes only and does not constitute formal chronic condition registration with KeyHealth Medical Scheme.

I acknowledge that, once my KeyHealth membership has been activated, KeyHealth’s appointed chronic disease management provider, MediKredit, will contact me to assist with and finalise the chronic registration process.

Consent and Acknowledgement

I acknowledge and agree that KeyHealth Medical Scheme and FinSide Financial Solutions, including any affiliated entities, shall not be held liable for any errors, omissions, or delays arising from incomplete, incorrect, or inaccurate information submitted by me in this application.

I further understand and agree that KeyHealth Medical Scheme and FinSide Financial Advisors reserve the right to request additional information, supporting documentation, or verification at any stage, as may be required to assess or process this application.

By submitting this form, I confirm my understanding of the above and provide my consent for the information supplied to be shared with KeyHealth Medical Scheme and its appointed service providers for the purposes outlined.