SHA Application for Registration Form
The SHA Application for Registration Form is the official form used to apply for registration with the Social Health Authority (SHA) in Kenya. It is titled “Application for Registration” and is issued under the Social Health Insurance Act, 2023 and the Social Health Insurance (General) Regulations, 2024.
The form is designed to collect the applicant’s personal details, employment information, contact details, dependants’ information and other details required for SHA registration or updating of existing information.
If you are looking for the SHA Application for Registration Form PDF, you can download the form and use the instructions below to understand what information is required before completing it.
The uploaded copy contains four pages and includes sections for registration, address and contact details, declaration of dependants, updating or amendment of information, declaration and official use.
Download SHA Application for Registration Form PDF
You can download the SHA Application for Registration Form PDF and print it for completion. Official SHA Application for Registration Form: Download the SHA Application for Registration Form PDF
The form should be completed carefully because it contains personal information that is used for registration and, where applicable, updating SHA records.
What is the SHA Application for Registration Form?
The SHA Application for Registration Form is a registration document for providing information required by the Social Health Authority. The document is headed “Social Health Authority Registration Form” and contains an application for registration section.
The form captures information about the principal member, including their name, employment type, date of birth, identification details, citizenship, KRA PIN and contact information. It also provides space for declaring dependants and for making certain amendments to existing information.
In addition to registering a member, the form contains an Updating/Amendment section. This allows the applicant to indicate changes such as a change of name, change of dependants, correction of date of birth, change of civil status, change of facility/PCN, or updating personal and contact information.
Sections of the SHA Application for Registration Form
The form is divided into several main sections. Understanding each section before you start filling it out can help you avoid leaving out important information.
1. Principal Member’s Personal Details
The first section collects the principal member’s personal information. You are required to provide details such as:
- Title
- Last name (surname)
- First name
- Middle name
- Employment type
- Preferred Primary Care Network (PCN)
- Date of birth
- Place of birth
- ID number
- Civil status
- Sex
- Citizenship
- KRA PIN
The employment type section provides options for employed, self-employed, sponsored and organised group. The citizenship section includes options for Kenyan, foreign national and resident. The form also specifically marks the KRA PIN as required.
2. Address and Contact Details
The second section of the SHA registration form is for your address and contact information.
The form provides fields for:
- Physical address
- Home phone number
- Mobile number
- Business phone number
- E-mail address
- County
- Sub-county
- Ward
- Postal address
- Province/state/country if abroad
- ZIP code if abroad
The mobile number is marked as required on the form.
When completing this section, provide accurate and current contact information. Your address and telephone details should be entered carefully to reduce the possibility of errors in your SHA records.
3. Declaration of Dependants
The Declaration of Dependants section is used to provide information about dependants associated with the principal member. The form provides a table with columns for:
- Last name (surname)
- First and middle name
- Relationship
- Date of birth
- Preferred PCN
There is space for several dependants on the form. If additional space is required, the form states “Use additional form if necessary.”
Dependants should be declared accurately. This is also specifically included among the instructions at the end of the form.
What information is needed for each dependant? For each dependant you declare, the form asks for their surname, first and middle names, relationship to the principal member, date of birth and preferred PCN. Make sure the information entered for each dependant is accurate and complete.
4. Check if With Permanent Disability
The form also includes a section labelled “Check if with Permanent Disability” within the dependant declaration area.
If applicable, ensure that the relevant information is completed as required when declaring dependants.
5. Updating or Amendment of SHA Information
The SHA Application for Registration Form is not limited to first-time registration. It also contains a section for Updating/Amendment. The applicant can indicate the type of information that needs to be changed or corrected.
The options provided include:
- Change or correction of name: Use this option when the information relating to your name needs to be changed or corrected.
- Change of dependants: This option is provided where information concerning dependants needs to be updated.
- Correction of date of birth: The form provides a specific option for correcting the date of birth.
- Change of civil status: This option allows the applicant to indicate that their civil status has changed.
- Change of facility/PCN: The form allows the applicant to request a change of facility or Primary Care Network. Where this option is selected, the form asks the applicant to indicate the reason for the change.
Updating personal information and contact details
The form also provides an option for updating:
- Personal information
- Address
- Telephone number
- Mobile number
- Email address
This is useful when the information previously provided to SHA is no longer current.
6. Declaration
The declaration section is where the member confirms the accuracy of the information provided. The form states that the applicant attests that the information provided, including attached documents, is true and accurate to the best of their knowledge and authorises SHA for validation and verification for legitimate purposes. The applicant is required to provide:
- Member’s signature
- Date
If the applicant is unable to write, the form instructs them to affix the right thumbmark.
7. For Official Use Only
The final part of the form is reserved for official use.
It includes information such as:
- Received by
- Full name
- Zone/Branch
- Date and time
The applicant should therefore pay attention to which sections are intended for them and which sections are reserved for SHA officials.
Requirements for Filling the SHA Application for Registration Form
The form itself provides instructions that applicants should follow when completing it. According to the form, the following requirements and instructions apply:
- Write all information in UPPER CASE/CAPITAL LETTERS. If a field is not applicable, write “N/A.”
- Mandatory fields must be completed unless they are specifically indicated as optional.
- First-time registrants require valid proof of identity.
- If you are updating information, check the appropriate section and indicate the correct data.
- Provide complete permanent and postal addresses and contact numbers.
- Affix your signature or right thumbmark and date the form.
- Declare dependants accurately.
These instructions are particularly important because incomplete or incorrectly entered information can make the form harder to process.
How To Fill SHA Application for Registration Form
Follow these steps when completing the form.
Step 1: Download and print the SHA form
Start by downloading the SHA Application for Registration Form PDF and printing the required pages.
Use the current version of the form rather than relying on an old copy that may contain outdated information.
Step 2: Fill in your personal details
Begin with the principal member’s personal details. Enter your title, surname, first name and middle name. Select the appropriate employment type and provide the other requested personal information.
Check your ID number, date of birth, citizenship and KRA PIN carefully before proceeding.
Step 3: Complete your address and contact details
Enter your physical address, mobile number, email address and other applicable contact details. Provide your county, sub-county and ward where requested. If you are abroad, the form also provides fields for province/state/country and ZIP code.
Step 4: Declare your dependants
If you have dependants to declare, enter each person’s information in the dependant table. Make sure that their names, relationship and dates of birth are entered correctly. If the available space is insufficient, use the additional form as instructed.
Step 5: Select an amendment if updating existing information
If you are not completing the form solely for registration but are updating existing information, select the relevant option under Updating/Amendment.
For example, you can indicate a change of name, change of dependants, correction of date of birth, change of civil status, change of facility/PCN or updating of contact information.
Step 6: Sign and date the form
After checking the information, complete the declaration section. Add your signature and date. If you are unable to write, follow the form’s instruction concerning the right thumbmark.
Step 7: Review the form before submission
Before submitting the form, check that:
- Your names are correctly spelled.
- Your ID number is correct.
- Your KRA PIN is correct.
- Your mobile number is correct.
- Your address details are complete.
- Your dependant information is accurate.
- The relevant registration or amendment option has been selected.
- You have signed and dated the form.
- Required supporting identification is available where applicable.
SHA Application for Registration Form for First Time Registration
If you are a first-time SHA registrant, the form provides a way to submit the personal, employment, identification and contact information required for registration.
The form specifically states that valid proof of identity is required for first-time registrants. Make sure you have the appropriate identification document available before completing the registration process.
SHA Application for Registration Form for Updating Details
You can also use the form where information needs to be updated or amended.
The amendment section covers several common changes, including a name change, dependant changes, correction of date of birth, civil status changes, facility/PCN changes and updates to personal or contact information.
This means you should not automatically complete the form as a brand-new registration when your purpose is to correct or update existing information. Instead, use the Updating/Amendment section and select the applicable option.
Important Things to Check Before Submitting the Form
A common mistake when filling an official form is concentrating only on the fields while overlooking the instructions.
For the SHA Application for Registration Form, pay particular attention to the following:
- Use capital letters: The instructions say that all information should be written in uppercase/capital letters.
- Use N/A where appropriate: If a field does not apply to you, the form instructs you to write “N/A.”
- Complete mandatory fields: Fields marked as mandatory should not be left blank.
- Check your contact information: The form requests several contact and address details, including a required mobile number.
- Provide proof of identity where required: First-time registrants are instructed to provide valid proof of identity.
- Sign and date the form: The declaration section requires the member’s signature and date.
- Declare dependants accurately: Check all dependant details before submitting the form.
SHA Application for Registration Form PDF Download
If you specifically searched for SHA Application for Registration Form PDF, the document you need is the four-page Social Health Authority registration form titled Application for Registration.
Download the official PDF here: SHA Application for Registration Form PDF
It is advisable to save a copy of the PDF on your phone or computer after downloading it so that you can refer to the form while preparing your information.
Frequently Asked Questions About SHA Application for Registration Form
1. What is the SHA Application for Registration Form?
The SHA Application for Registration Form is the registration document used to collect information from a principal member for Social Health Authority registration. It also contains sections for declaring dependants and updating or amending certain member information.
2. Where can I download the SHA Application for Registration Form?
You can download the SHA Application for Registration Form PDF from the official SHA website using the PDF link provided above.
3. Is the SHA Application for Registration Form available as a PDF?
Yes. The application form is available as a PDF document and contains four pages.
4. What information does the SHA registration form require?
The form requests personal details, employment type, preferred PCN, date and place of birth, ID number, civil status, sex, citizenship and KRA PIN. It also requests address and contact details and provides a section for declaring dependants.
5. Is a KRA PIN required on the SHA Application for Registration Form?
Yes. The form labels the KRA PIN field as “Required.”
6. Is a mobile number required on the SHA registration form?
Yes. The mobile number field in the address and contact details section is marked “Required.”
7. Can the form be used to update SHA information?
Yes. The form contains an Updating/Amendment section for changes such as name, dependants, date of birth, civil status, facility/PCN and personal or contact information.
8. What should I write if a field does not apply to me?
The form’s instructions state that if a field is not applicable, you should write “N/A.”
9. Do first-time SHA registrants need proof of identity?
Yes. The form states that filled forms require valid proof of identity for first-time registrants.
10. Do I need to sign the SHA Application for Registration Form?
Yes. The declaration section includes a member’s signature and date. The form also states that a right thumbmark should be affixed if the applicant is unable to write.
Final Checklist
Before you submit your SHA Application for Registration Form, make sure you have:
- Downloaded the current SHA Application for Registration Form PDF.
- Written the required information in capital letters.
- Completed all applicable mandatory fields.
- Used “N/A” where a field does not apply.
- Provided valid proof of identity if you are a first-time registrant.
- Entered complete address and contact details.
- Provided the required mobile number.
- Entered your KRA PIN correctly.
- Declared your dependants accurately.
- Selected the appropriate amendment option if updating information.
- Signed and dated the form.
- Affixed the right thumbmark if unable to write.
The most important thing is to download the correct SHA Application for Registration Form, follow the instructions printed on the form, complete the applicable sections accurately and review your information before submission.