Fillable Overseas Visitors Health Cover Interactive Claim Form (Australian National University)

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Overseas Visitors Health Cover Interactive Claim Form (Australian National University)

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The Overseas Visitors Health Cover Interactive Claim Form (Australian National University) form is 2 pages long and contains:

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  • 7 check-boxes
  • 46 other fields

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Overseas Visitors Health Cover
Interactive Claim Form
Attach to this email:
• All receipts, invoices and documents relevant to your claim. Please keep a copy of all documents for your records.
• A copy of your passport and visa.
• Documentation in Section 5. As each claim is unique, we may request further information.
Section 1 - Policyholder Details:
Policy/member number (must be provided):
Title: Dr / Mr / Mrs / Miss / Ms Family Name (last name):
First Name: Other name/s:
Date of Birth: Gender: M F Prefer not to say
Home address
(Name and street number):
Suburb: State: Postcode:
Mobile number: Alternative number (optional):
Email address:
Nationality: Passport Number:
Do you have any other type of health insurance (in home country, Medicare etc.) ?
If YES, please provide the name of the insurer and your policy number.
Section 2 - This section must be completed for all claims (drop down options can be found in the form attached)
Will you also be claiming through any compensation or damages provisions ?
(e.g. workers compensation, transport accident laws or by any government sponsored fund etc.)
Please select what the expenses are being claimed for:
Please read the ‘What’s not covered’ section(s) in our Policy Wording for more details.
If the claim is related to an accident (i.e. Motor vehicle, motorbike/scooter, workplace or sporting), please complete the Accident
Information Form located on www.allianzcare.com.au
Section 3 - Details of expenses claimed:
Patient’s legal name
Service/treatment provided
e.g. Specialist consult, blood
test, x-ray etc.
Date of service/
treatment
Amount on
invoice
Have you already
paid for this
service?
1.
2.
3.
4.
5.
• If you have not yet paid your invoice, the amount payable under your policy may be paid directly to the medical service provider. Please direct the
provider to contact Allianz Care Australia by calling 1300 727 193 if they have any enquiries.
Allianz Care Australia will endeavour to process your claims within 10 working days of receiving a completed claim form and copies of all required documentation.
Allianz Care Australia Overseas Visitors Health Cover is managed by AWP Australia Pty Ltd ABN 52 097 227 177. 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 Visitors Health Cover policies.
1
Yes
Select
Yes
2
Section 4 - Payment to Australian Bank Account by Electronic Funds Transfer
Please provide bank account details to ensure prompt payment (only complete if you have already paid the account and have attached copies
of tax invoices and receipts). If correct bank details are not provided, a cheque will be sent to your Australian postal address.
Name of financial institution:
Name of account holder:
BSB number:
Account number:
Section 7 - Authorisation
If you wish to provide approval for someone else to speak or act on your behalf about this claim you must complete the following
details (otherwise we will not be able to give any information about your claim to any other person).
A I/we, authorise (Full Name):
D.O.B:
Of (Address):
Mobile:
To act on my behalf in respect to this claim and to be provided with information relating to this claim.
Section 5 - Required documentation
In addition to documents we requested as outlined above, we may require some further information depending on your claim. Please see the
documentation we may need below and if it applies to you, make sure you provide these documents ( mark as provided)
Please note your claim may not be accepted without relevant documentation as outlined below.
Ambulance report. If you were transported to hospital via ambulance, please also complete and submit an Ambulance claim form
(download form at www.allianzcare.com)
Injury/incident. If you were in a sporting event or at work, please also complete and submit an Accident Information form
(download form at www.allianzcare.com)
Section 6 - Declaration
I declare that all statements and particulars contained on this claim form are true and correct.
I authorise Allianz Care Australia to contact the hospital, an insurer or insurance reference bureau, or provider of any service for further
clarification of details relating to this or any other claims I have made.
Tick here to agree to these conditions.
Date:
Please return completed form and all required documentation to:
Email: OVHCclaims@allianzcare.com.au
Fax: + 61 7 3305 7009
Post: Allianz Care Australia, OVHC Claims, Locked Bag 3004 Toowong QLD 4066 Australia
Please send this form, your receipts, medical certificate
and ambulance claim form (if applicable, see section 5) to:
✔
SUBMIT
3
Section 8 - Did you know?
To assess claims, Allianz Care Australia may request the original documentation and any further documents within 90 days after claim
submission for auditing purposes.
Direct Billing Medical Providers
Allianz Care Australia has an extensive network of medical providers around Australia. This means the invoice/account is sent directly to Allianz
Care Australia. You will only be required to pay if the medical provider charges a co-payment, which is an additional amount above the
scheduled Medicare fee. Find your local Direct Billing Medical Providers online at www.allianzcare.com.au under the ‘Find a doctor’ section.
Online Services – www.allianzcare.com.au
Visit our website to:
• Submit online claims
• Renew your policy
• Read health and wellbeing information
• Find a Doctor
24 Hour Emergency Helpline – 1800 814 781
Emergency access to medical advice, legal and interpreting services. Limited legal advice is also available during business hours.
Waiting Periods
Budget, Standard, Mid and Top Cover
• 2 months for pre-existing psychiatric-related medical conditions.
• 12 months for pregnancy related medical services.
• 12 months for all other pre-existing medical conditions.
Mid or Top Working Cover, additional waiting periods apply to extras cover including
• 2 months waiting period for general dental, physiotherapy, chiropractic, podiatry, psychology, speech therapy, health aids, Chinese medicine
consultations and complementary therapies.
• 6 months waiting period for optical and health management programs.
• 12 months waiting period for major dental.
• 24 months waiting period for laser eye surgery and hearing aids.
Your waiting period will start from either:
• the date you or your dependant (as the case may be) arrived in Australia; or
• the date your visa was granted; or
• the date your policy commenced,
whichever is the later date.
See your policy document for further details in relation to waiting periods
4
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.allianzcare.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 Australia, 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.
Allianz Overseas Visitors Health Cover Interactive Claim Form - Ver_01_OCT_2021
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Completed 2 June 2022

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