Part B: Patient's Treating Doctor
Members of Allianz Care Australia OSHC have agreed, in respect of
any claim, to allow Allianz Care Australia to provide details of their
cover and to obtain details from any health care provider in order
to process their claims (refer Allianz Care Australia OSHC Policy
Document). Important: The medical practitioner is requested to give
as much details as possible in order to assist our member and avoid
the necessity of additional enquiries.
Medical Practitioner name:
Medical Centre name:
Address:
State: Postcode:
Phone/Fax:
How long have you been the treating Medical Practitioner for the
above patient?
Describe the nature of the presenting symptoms and diagnosis:
Date of onset of condition/illness/injury:
__
/
__
/
____
What was the date you first investigated or were consulted by the
patient for this condition/illness/injury?
__
/
__
/
____
Has the patient previously been investigated, diagnosed or
treated by another doctor in respect of the same, similar or related
condition/illness/injury as described above?
Yes No
If yes, please provide details:
Please provide brief details of the patient’s medical history with
regards to this or related conditions/illnesses/injuries:
Proposed treatment plan likely to be required:
Short term
(<6 weeks) Medium term (6 – 12 weeks)
Long term
(12 weeks +)
Details of treatment plan:
I certify that the statements contained in this Medical
Certificate are true and correct.
Signature of Medical Practitioner:
Date:
__
/
__
/
____
Part A: Patient Information
Policy number:
Family name: (Last name)
Given name:
Date of birth:
__
/
__
/
____
Passport Number:
Country of Issue:
Phone:
Email address:
Address:
State: Postcode:
I hereby authorise the release to AWP Australia Pty Ltd trading as Allianz
Care Australia of any relevant information, including health information
held by a treating doctor or by a hospital at which I received treatment,
for the purpose of Allianz Care Australia administering any claim in
relation to that treatment under my health cover.
I consent to the use and disclosure of my information as specified under
the heading ‘Privacy Notice’ below and in accordance with the Allianz
Care Australia OSHC Policy Document.
Signature of patient:
If you are under 18 years of age, your parent or legal
guardian must provide consent on your behalf.
Name:
Relationship:
Signature of parent/guardian:
Date:
__
/
__
/
____
Please email the completed form to
oshcclaims@allianzcare.com.au or fax to (07) 3305 7009.
Overseas Student Health Cover
Medical Certificate
P00
Privacy Notice
Your privacy: Your privacy is important to us. To arrange, oer, and provide you with our products and services (or those we may oer or provide to you on behalf of our business
partners) and for the purposes set out below, we, namely AWP Australia Pty Ltd ABN 52 097 227 177 trading as ‘Allianz Care’, collect, store, use, process, and disclose your
personal information including sensitive information such as medical information in accordance with the requirements of privacy laws. For full details of our privacy policy, please
visit our website at www.allianz-assistance.com.au and click on the Privacy & Security link.
When we collect your personal information, we are responsible for ensuring it is processed and protected in accordance with applicable privacy laws such as the Privacy Act 1988
(C’th), and sometimes European Law such as the GDPR where our activities fall within its scope. Personal information we collect includes, for example, your name, address, date of
birth, email address, your medical information, passport details, and bank account details. We also collect information through devices such as ‘cookies’ when you visit our website
or use our mobile apps, in order to improve our website functionality and user experience.
Data Collection: We usually collect your personal information directly from you but sometimes from others depending upon the circumstances and the product involved. For
example, to quote, arrange, or provide our health insurance products and services, we may collect your personal information from you, your agents, our agents, your broker, other
insurers, universities and learning institutions, Government departments managing Immigration, health, and foreign aairs including for visa purposes, family members including
your partner or spouse, travelling companions, as well as from doctors, hospitals, and other health service providers if you require medical assistance. We may collect your
personal information from our business partners and agents whom you may have approached or who distribute or help provide or arrange our products and services.
Purposes & Uses: We use your personal information to arrange, oer, and provide our products and services (or those we may oer or provide to you on behalf of our business
partners) and to manage your and our rights and obligations in connection with any products and services you have inquired about or acquired. For instance, we use it to assess,
process, and investigate health insurance claims, and to liaise with Government Departments such as immigration, health, and foreign aairs where it relates to your cover
or your application for private health insurance cover. We may also use it for product development, marketing (where permitted by law or with your consent), customer data
analytics, research, IT and related systems maintenance and development, recovery against third parties, fraud investigations, to comply with requests from regulatory bodies
and government departments, and for other purposes with your consent or where permitted by law. We do not sell your personal information to any other person or entity for
marketing purposes.
Disclosures & overseas transfers: Your personal information may be disclosed to your family members, co-insured on the same policy, your spouse or partner, as well as to third
parties who assist us to carry out the activities set out in the ‘Purposes & Uses’ paragraph above, such as claims management providers, our agents and intermediaries, insurers,
investigators, cost containment providers, medical and health service providers, universities and other education institutions, overseas data processing and ‘cloud’ storage
providers, legal and other professional advisers, your agents and broker, your travel group leader if you travel in a group, your employer or sponsor, insurance reference bodies,
and our related entities in the Allianz group of companies including Allianz Partners. Some of these third parties to whom your personal information may be disclosed and
transferred, will be located in other countries including in Europe, the UK and Ireland, Asia, Canada, or the USA. We also, where necessary, disclose your personal information to
Government Departments that manage immigration, health, and foreign aairs, as well as to regulatory bodies including those involved in the health insurance industry. We also
disclose and transfer your personal information to our private health insurer that underwrites your policy, namely Peoplecare Health Limited, which is a registered private health
insurer, ABN 95 087 648 753. When we disclose or transfer your personal information to third parties, we take steps binding those entities to comply with privacy law.
Marketing: We may, where permitted by law or with your consent, contact you by telephone, normal mail, email, electronic messages such as SMS, and via other means with
promotional material and oers of products or services from us, our related companies, and business partners that we or they consider may be relevant and of interest to you.
Where we contact you as a result of obtaining your consent, you can withdraw your consent at any time by calling us on 1800 023 767 or by contacting us – see below.
Other individuals/dependents: Except where you have legal authority to provide personal information on behalf of another, such as in your capacity as a parent or legal
guardian, when you provide personal information to us about another individual on your policy such as your spouse, partner, family member, dependent, or adult children, we rely
on you and you warrant to us that you have first obtained that individual’s consent, and have made them aware of the matters set out in this Privacy Notice.
Access to and correction of personal information: You may also seek access to your personal information (or that of another on your policy where you are authorised to do so)
and ask us to correct or update it, and to obtain details about our data processing activities in respect of your personal information. You may have further rights in respect of your
personal information where the GDPR law applies, and depending upon the circumstances, you may request a restriction on processing, request it be deleted, and to receive it in
a portable form, amongst other things.
Withdrawal of consent: Where your personal information is used or processed with your specific consent as the sole basis for such use and processing (rather than on a
contractual basis or legitimate interests of the company), you may withdraw your consent at any time. Just contact us as set out below.
Contact us: If you wish to make a complaint about your data privacy, or have a request for access or correction, or any query about your personal information, please contact:
The Privacy Ocer, Allianz Care, PO Box 162, Toowong, QLD 4066, or email DataPrivacyAU@allianz-assistance.com.au or phone us on +61 7 3305 7000.
You can also contact the Privacy Commissioner at the Oce of The Australian Information Commissioner, GPO Box 5218, Sydney, NSW, 2001 if you have a complaint.
Without your agreement to the matters set out above, we may not be able to provide you with our products or services including the assessment and payment of any claims.
[version: 7 Feb 2020]
Allianz Care Australia Overseas Student Health Cover policies are authorised under a Deed entered into between Peoplecare Health Limited and the Australian Government
through the Department of Health. Allianz Care Australia Overseas Student Health Cover is managed by AWP Australia Pty Ltd ABN 52 097 227 177 trading as Allianz Care
Australia. Peoplecare Health Limited ABN 95 087 648 753, a private health insurer under the Private Health Insurance Act 2007 (Cth), is the underwriter of Allianz Care Australia
Overseas Student Health Cover policies.