CLAIM FORM CHECKLIST
Name of patient and date of each treatment
Name & qualifications of treatment practitioner
Prescription receipts specifying drug/s and prescription number
Eftpos receipt print-offs are NOT suitable for claim purposes
All items claimed go in the Refund Details section of the claim form. Don’t forget to include the reason for treatment as this is vital for processing your
WHAT HAPPENS NEXT
We aim to have all claims processed within 10 working days (usually shorter).
Claim payments are made every Wednesday and should appear in your nominated account the next day. Details of your claim payment will be sent to you.
Remember to send claim form and invoices
as PDF or JPG attachments.
All injury related medical expenses need to be first referred to ACC.
No refunds will be paid when subscriptions are in arrears.
Work-related treatment costs:
• Current serving members of Police must go to their Police District Human Resources Office for reimbursement of treatment costs associated with an injury
sustained at work, and for ACC purposes, be accepted as a work accident.
If NZ Police will not meet such costs and members have confirmation of that, they can submit a claim to Police Health Plan.
(04) 496 6800 or 0800 500 122
(04) 496 6819
PO Box 12344, Wellington 6144
Once completed, send to Police Health Plan:
Police Health Plan, PO Box 12344, Wellington 6144
This document collects personal information about you so Police Health Plan Ltd can consider your claim. The information is received and held by Police Health Plan
Ltd, PO Box 12344, Wellington 6144. You may request access to, and correction of, this information according to the provisions of the Privacy Act 1993.
Police Health Plan Ltd is a member of Health Funds Association of New Zealand (HFANZ). On behalf of its members, HFANZ manages an Integrity Registry for the
purposes of detecting and preventing fraud and other serious probity concerns. The Integrity Registry is operated by PricewaterhouseCoopers. In submitting this form
you are authorising Police Health Plan Ltd to collect, use and disclose personal and health information about you for the purposes of the Integrity Registry. You can
access and correct information held on the Integrity Registry. Contact Police Health Plan Ltd or HFANZ Integrity Registry Privacy Ofcer, Health Funds Association of
New Zealand, PO Box 25161, Wellington 6146.
• I declare to the best of my knowledge the details given in this claim form are true.
• I agree that Police Health Plan Ltd may give or obtain from appropriate individuals or organisations information relevant to evaluate and administer this claim.
• With regard to any injury or illness, I hereby authorise any hospital, physician or other person who has attended me to furnish Police Health Plan Ltd, or its
representatives, with any and all information with respect to any medical history, consultation, prescription or treatment and copies of all hospital or medical records.
• I agree that an electronic version of this authorisation shall be considered as effective and valid as the original and that electronic invoices submitted are copies of
the original invoices (please retain the original invoices in case we require them later).
If completing electronically, put an “X” in this box to
conrm consent to the above declaration.
Originals of any accounts/receipts or if submitted electronically, attached as a PDF or JPG.
Avoid processing delay by submitting easily readable receipts (refer www.policeassn.org.nz for full guidelines).
All invoices/receipts must show: