Pre-approval Form PH 01

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Healthcare99

Healthcare99 is available to members at an extra cost

NZ Firefighters Welfare Society members can join Healthcare99 and claim assistance with meeting many medical costs

Healthcare99 A&B

You can claim $500 per person, per year

The Wellness Benefit is available with both Options A and B

"*" indicates required fields

First Name*

Last Name*

Email*

This section is about the patient information.

First Name*

Last Name*

Address*

Street Address Address Line 2 City Postcode

Patient's Date of Birth*

Phone Number*

Is this an ACC Claim?*

Yes - ACC claims are not covered. Refer to policy wordings for full details

No - Please proceed

Diagnosis*

Proposed Treatment*

Name of Provider/Specialist*

Estimated Cost*

Please upload your specialist report/GP referral

Drop files here or

Max. file size: 10 MB.

Please upload all quotes/estimates

Drop files here or

Max. file size: 10 MB.

Name of Hospital/Clinic

Date of Procedure

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