The insured member is required to complete the following claim form and attach all the original medical bills and supporting documentation when fling the claim. A separate claim form must be completed for each medical condition, each currency and each member. All sections must be completed.
SECTION A: PATIENT DETAILS TO BE COMPLETED BY INSURED MEMBER
Name of Main Applicant:
Date of Birth:
Name of Patient (If other than the main Applicant):
Date of Birth:
Present Contact Address:
Email Address for Remittance Advice:
SECTION B: SETTLEMENT DETAILS
We settle all eligible claims by bank transfer (EFT), therefore it is important that you confrm 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 felds in the box below are MANDATORY:
Name of Main Bank Account Holder:
Benefciary Bank Account No:
Account Holder address (residential address registered with the bank):
Name of Bank, Branch and Location:
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
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.
Signature of Main Applicant
Signature of Patient
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. What was the date of the frst consultation?
3. Please specify 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 Clinic:
Name of Physician/Surgeon and Qualifcations:
Signature of Physician/Surgeon: