Claim Form Date Received:
PERSONAL DETAILS OF POLICY HOLDER
Membership Number:
Full Name: Date of Birth:
Postal Address:
Work Phone:
Mobile Phone:
Postcode:
Home Phone:
Preferred Email:
Alternative Email:
Place of Work:
Position Held:
MY BANK DETAILS:
Account Number:
BANK BRANCH ACCOUNT NUMBER SUFFIX
PLEASE NOTE: All claims will be paid directly into the bank account provided by you above (Cheques are no longer issued)
NAMES AND DATES OF BIRTH OF PEOPLE FOR WHOM REIMBURSEMENT IS BEING CLAIMED:
Date of Birth:
Name:
Date of Birth:
Name:
Name:
Name: Date of Birth:
Name:
Date of Birth:
Name:
DECLARATION THIS MUST BE COMPLETED IN ALL CASES
1. I am a Union member: YES NO Name Of Union:
2. The events under claim are subject to reimbursement from another source.
YES NO
(e.g. medical insurance, ACC, linked and approved HealthCarePlus Hospital Cover Provider)
Name of other source:
Payment advice received from this source is attached.
YES NO
I understand that this claim will be treated in confidence and in accordance with the terms and conditions current at the
time the events under claim occurred.
I consent to receiving all documentation that is required by law to give me in electronic form and I consent to
communicating with me via the preferred email address specified in this claim form.
DATE:
HealthCarePlus
5. In submitting this form I certify that the surgery, treatment or procedure was performed and all particulars shown on
this claim are true and correct. I authorise UniMed to obtain any further medical information they may need in
connection with this claim submitted by me or my listed dependants. UniMed may disclose information related to this
claim to the Integrity Register for the purposes of the detection of fraudulent and suspicious conduct.
6. I confirm that I am authorised by each person named in this claim form to complete and sign on their behalf.
SIGNATURE OF APPLICANT:
PRIVACY ACT Pursuant to the Privacy Act 2020 the following is brought to your attention:
(a) This claim form and any supporting documents collect personal information about you and is collected to effect the claim you make.
(b) In assessing and processing your claim UniMed may need to collect, disclose or use your personal information, including the collection of
information from third party health service providers.
(c) You are required to provide all information that is material to a claim. If you fail to provide this information or provide inaccurate information it
may result in your claim being delayed or declined or Membership voided.
(d) Each person in this claim form authorises UniMed to obtain from any party or organisation (including health care providers) any information
reasonably required to evaluate and investigate this claim, and each person named in this claim form authorises that party or organisation to
disclose such information to UniMed.
(e) In completing and submitting this form you consent to the collection, disclosure and use of your information in accordance with the Privacy Act
2020
, the Health Information privacy Code and the Privacy Statement contained in the UniMed/HealthCarePlus Conditions of Membership. You
also consent to the collection, disclosure and use of your information for the purposes of the Integrity register.
Date of Birth:
Date of Birth:
