CLAIM FOR MEDICAL EXPENSES
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.
Signed _________________________________________________________________________ Date __________________________________
I would like any refund credited to my bank account: (Please complete) Use this bank account No. for:
(Please tick)
For this claim only
For all future claims
MEDICAL EXPENSES WHICH I AM SEEKING REIMBURSEMENT
Please list accounts for all expenses individually. The actual conditions/symptoms treated must be shown. “GP visit”, “X-ray” and the like are not sufficient.
PATIENT DATE OF BIRTH PROVIDER/SERVICE
REASON FOR VISIT
OR SERVICE
DATE OF VISIT AMOUNT PAID
Sally 01/01/40 e.g. GP Visit e.g. sore throat, flu 01/12/14 $25.00
CLAIM FOR MEDICAL EXPENSES
REIMBURSEMENT TO MEMBER
POSTAL ADDRESS
PO Box 1721, Christchurch 8140
Phone: 0800 600 666
HEAD OFFICE
165 Gloucester Street, Christchurch 8011
www.unimed.co.nz
claims@unimed.co.nz
PATIENT’S NAME MEMBERSHIP NO.
FULL ADDRESS
EMAIL ADDRESS
Attach
Original Receipts and Invoices Here
PRESCRIPTIONS
Pharmacist receipts must show the name of the patient, prescription number, the name and cost of each medication prescribed.
Each prescription charge is to be listed individually.
PATIENT DATE OF BIRTH MEDICATION DATE OF VISIT AMOUNT PAID
Sally 01/01/40 e.g. Augmentin 01/12/14 $25.00
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL CLAIM
$
ACCEPTANCE CHECKLIST
(Please tick)
All claims are supported by the original itemised accounts and receipts showing the name of the patient, date of consultation, description
of service, qualification and GST number of the provider. (EFTPOS and credit card receipts are not acceptable without the original itemised
accounts).
Receipts exceed $50 in total, unless no claim made in a year, and are less than 15 months old from the date of incurring the cost.
An itemised account, if claiming for multiple visits, attached.
Accounts and receipts are attached in the same order as listed on the claims form.
The declaration is signed.
My address has changed since the last claim.
PUBLIC HOSPITAL ADMISSION
(Please tick)
The ‘Public Hospital Cash Grant’ payment will only be made on receipt of the Hospital Discharge notice.
Attached
The Privacy Act 1993 requires UniMed to inform you about certain rights and obligations relating to the information which we collect on this form.
In this regard we recommend that you read the Privacy Statement on our webpage www.unimed.co.nz. The Integrity Register is a register of health
insurance claims and administered by PwC (on behalf of HFANZ) for the purposes of the prevention and detection of fraudulent and suspicious conduct.
The collection of information complies with the Privacy Act 1993 and the Health Information Privacy Code 1994.
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