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Get SG CPF MSH4 2013-2024

MSH4 Central Provident Fund Board 79 Robinson Road CPF Building Singapore 068897 Website www. cpf.gov.sg CPF Call Centre 1800-227 1188 Opt Out/Termination of MediShield Cover This form may take you 3 minutes to complete. Please read the following important notes carefully 1. MediShield is a basic medical insurance scheme. It is designed to help pay part of the expenses arising from the insured s hospitalisation and for certain outpatient treatments at approved medical institutions. MediShield works most effectively for hospitalisations at B2/C class level at restructured hospitals. It is meant to complement a member s Medisave savings in the event of prolonged illnesses that require longer-term medical treatment. Please consider carefully before you opt out or terminate your/your dependants MediShield cover s. 2. Approval to rejoin the scheme is subject to assessment of your/your dependant s health condition s at the point of re-application* Any serious pre-existing medical condition may be excluded from coverage or the application may be declined* 3. If your dependant is 16 years old and above and wishes to terminate his/her cover he/she would need to complete this form himself/herself* If your intention is to stop premium payment for your dependant s please complete form MSH8 Stop Premium Payment for your Dependant s MediShield Cover instead* 4. Please do not use correction fluid/tape on this form* Please sign against any amendments/cancellations you have made on the form* 5. Please send the original completed and signed form to CPF Board. PART I PARTICULARS OF APPLICANT As in NRIC Delete where applicable Name NRIC/CPF Account Contact No* Home S/T Office Mobile PART II OPT-OUT/TERMINATION FOR SELF/ DEPENDANT S Please tick where applicable I wish to opt out / terminate the MediShield cover for Myself My Dependant s aged below 16 listed below Name of Dependant aged below 16 As in NRIC / Birth Certificate NRIC / Birth Certificate Number 1. - I agree that the last day of the MediShield cover for me and my dependant s will be the date the CPF Board receives this original signed Opt Out/Termination form* I understand that I / my dependant s can be included in the MediShield Scheme again only on application and will be required to make a health declaration and may have to undergo a medical assessment or submit a medical report at the time of application* Signature/Right Thumb Print of Applicant For Official Use Checked By MSH/01032013 Date. Please read the following important notes carefully 1. MediShield is a basic medical insurance scheme. It is designed to help pay part of the expenses arising from the insured s hospitalisation and for certain outpatient treatments at approved medical institutions. It is designed to help pay part of the expenses arising from the insured s hospitalisation and for certain outpatient treatments at approved medical institutions. MediShield works most effectively for hospitalisations at B2/C class level at restructured hospitals.

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