Health Insurance Claim Form


Membership Number


Your Personal Details

Title
First Name
Last Name

Date of Birth
Home Phone

Mobile Phone
Email

Mailing Address
Mailing Address Line 2

City/Town
State/Province
Postal/Zip Code


Claim Details

Please enter:
Patient Name
Date of Service
Type of Treatment
Practitioner Name
Have you paid the account?
1
 
 
 
 
 
2
 
 
 
 
 
3
 
 
 
 
 
4
 
 
 
 
 
5
 
 
 
 
 


Hospital Details

Were you admitted as an inpatient in hospital?
Yes
No



Declaration

I hereby declare that the information I have provided in this application is true and correct to my best knowledge.

Signature of Member


Submit
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