72465 unimed claims forms

POSTAL ADDRESS
HEAD OFFICE
IMPORTANT - PLEASE READ CAREFULLY
Please list receipts for all medical costs and ALL PRESCRIPTION CHARGES INDIVIDUALLY, below.
“Consultation” or “check up” is NOT sufficient for the “Reason for Visit” section (this information is for auditand planning purposes and helps ensure that benefits are kept current).
CLAIMS FORM
All claims cheques are payable to the member.
Acceptance Checklist
Reason for visit (must be advised)
Are all accounts paid, and the original accounts WITH receipts attached to the claims form? Receipts must exceed $50 for your claim to be accepted (unless you have not claimed in Are all receipts less than 15 months old? (They must be for the Society to refund them.) If claiming for multiple visits on one receipt have you attached an itemised account fromyour doctor? Is the claims form fully completed (both sides) including a precise description of the nature of illness for each visit? NB “consultation” or “check up” is NOT sufficient.
Has the Hospital admission section (if applicable) been completed by the attendingphysician or surgeon? HAS YOUR ADDRESS CHANGED SINCE YOUR LAST CLAIM? I certify that all particulars shown on this form are true and correct and I hereby authorise UniMed to obtain any further medical information they may need in connection with any claim submitted by me or my listed LIST PRESCRIPTIONS HERE (for “Reason for Visit” put medication name from chemist’s receipt) PUBLIC/PRIVATE HOSPITAL ADMISSION (Cross out one).
This panel must be completed by the attending Physician or Surgeon or, in the case of a Public
Hospital, by the Medical Records Office.
Was this condition due to personal injury by accident or an employment related condition? Yes/No PLEASE NOTE:
It will greatly assist our claims staff if your receipts are attached to the claims form in the same order as they are listed above. This will enable your claim to be processed with the minimum delay.
PLEASE TURN OVER FOR GENERAL MEDICAL EXPENSES CLAIMS.
HAVE YOU COMPLETED THE FRONT OF THIS FORM?
POSTAL ADDRESS
HEAD OFFICE
IMPORTANT - PLEASE READ CAREFULLY
Please list receipts for all medical costs and ALL PRESCRIPTION CHARGES INDIVIDUALLY, below.
“Consultation” or “check up” is NOT sufficient for the “Reason for Visit” section (this information is for auditand planning purposes and helps ensure that benefits are kept current).
CLAIMS FORM
All claims cheques are payable to the member.
Acceptance Checklist
Reason for visit (must be advised)
Are all accounts paid, and the original accounts WITH receipts attached to the claims form? Receipts must exceed $50 for your claim to be accepted (unless you have not claimed in Are all receipts less than 15 months old? (They must be for the Society to refund them.) If claiming for multiple visits on one receipt have you attached an itemised account fromyour doctor? Is the claims form fully completed (both sides) including a precise description of the nature of illness for each visit? NB “consultation” or “check up” is NOT sufficient.
Has the Hospital admission section (if applicable) been completed by the attendingphysician or surgeon? HAS YOUR ADDRESS CHANGED SINCE YOUR LAST CLAIM? I certify that all particulars shown on this form are true and correct and I hereby authorise UniMed to obtain any further medical information they may need in connection with any claim submitted by me or my listed LIST PRESCRIPTIONS HERE (for “Reason for Visit” put medication name from chemist’s receipt) PUBLIC/PRIVATE HOSPITAL ADMISSION (Cross out one).
This panel must be completed by the attending Physician or Surgeon or, in the case of a Public
Hospital, by the Medical Records Office.
Was this condition due to personal injury by accident or an employment related condition? Yes/No PLEASE NOTE:
It will greatly assist our claims staff if your receipts are attached to the claims form in the same order as they are listed above. This will enable your claim to be processed with the minimum delay.
PLEASE TURN OVER FOR GENERAL MEDICAL EXPENSES CLAIMS.
HAVE YOU COMPLETED THE FRONT OF THIS FORM?

Source: http://www.superlife.co.nz/files/attachments/Forms/Insurance/Unimed%20claim%20form.pdf