SECTION A: PATIENT DETAILS TO BE COMPLETED BY INSURED MEMBER Name of Main Applicant * Membership Number: * 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 Membership Number: Name of Patient: Sex: Male Female Date of Birth 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. Should the incorrect bank details be provided we reserve the right to charge an administrative fee to cover any charges incurred due to the error.
Total amount claimed (including currency): * Currency of Reimbursement: * Bank Transfer – All fields in the box below are MANDATORY:
If the account holder is not the claimant then you must state their relationship with the claimant and provide evidence of their permission for the funds to be transferred to their account (except in the case of a minor):
Name of Account Holder (as it appears on bank statement) * Relationship to claimant * IBAN where applicable Routing/intermediary information if required Beneficiary Bank Account number (only if IBAN not applicable) Account Holder Address (residential address registered with the bank): * Name of Bank, Branch and Location: * Swift Code/BIC: Sort Code (for UK banks only):
• 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
• If IBAN numbers are not used please ensure that the account number is entered and that the Swift Code/BIC is also completed.
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. Diagnosis (BLOCK CAPITALS PLEASE) * Date of First Consultation? * Onset Date of Symptoms: * Date Treatment Received: * Nature of Treatment: * Name of Physician/Surgeon and Qualifications: * Name of Clinic: * Address of Clinic: * Doctor or Clinic Telephone Number: * Doctor or Clinic Email Address * SECTION D: UPLOAD SECTION Please upload your documents below, failure to do so will delay your claim DECLARATION & AUTHORISATION
(This part must be signed by the patient or patient’s parent/legal guardian if the patient is below 18 years of age).
I hereby authorise any hospital, physician, person or organisation to disclose all information with respect to any illness, injury, medical history, consultations, prescriptions or treatment, and copies of all hospital or medical records. A photostat copy of this authorisation shall be considered as effective and valid as the original.
I certify that the above statements and answers are true and complete to the best of my knowledge and belief. * Main Applicant * Date * Patient * Date *