SECTION A: PATIENT DETAILS TO BE COMPLETED BY INSURED MEMBER Name of Main Applicant * Membership No.: * Date of Birth * Sex: * Male Female Present Contact Address: * Telephone number: * Email Address for Remittance Advice *
If the person named above is not the patient, please complete details Name of Patient: * Membership No.: * Date of Birth * Sex: * Male Female SECTION B: SETTLEMENT DETAILS
We settle all eligible claims by bank transfer (EFT), therefore it is important that you confirm your correct bank details every time you make a claim. Due to new regulation in the banking sector, we also need you to provide us with your residential address (registered to your bank account) so that we can pay claims directly into your bank.
Total amount claimed (including currency): * Currency of Reimbursement: * Bank Transfer – All fields in the box below are MANDATORY: Name of Main Bank Account Holder: * Beneficiary Bank Account No: * Account Holder address (residential address registered with the bank): * Name of Bank, Branch and Location: * Swift Code/BIC: Sort Code (for UK banks only): IBAN number:
• It is important that you complete the bank details section in full. Any missing or unclear information may result in payments being delayed.
• Bank charges may apply when making bank transfers
• Payments are not made directly to any clinic, physician or medical provider
SECTION C: PATIENT DETAILS TO BE COMPLETED BY TREATING DOCTOR Note: If there are multiple doctors, this section is to be completed by the last attending physician. 1. Diagnosis (BLOCK CAPITALS PLEASE) * 2. Date of first consultation? * 3. Onset date of symptoms: * 4. Date Treatment received: * 5. Nature of Treatment: * 6. Doctors previously consulted by the patient for the above condition: Name of Physician/Surgeon and Qualifications: Name of Clinic: Address: Contact No.: SECTION D: UPLOAD SECTION Please upload your documents below, failure to do so will delay your claim