Healthcare99 Claim form - Out of Hospital - New Zealand Firefighters Welfare Society

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Healthcare99

Contact Healthcare99

Phone: 0800 65 34 73 EXTN 2
Email: NZ.HEALTHCARE99@GBTPA.CO.NZ

Healthcare99 Claim form – Out of Hospital

"*" indicates required fields

Member

First Name*

Last Name*

Email*

Phone Number*

Address

Street Address Address Line 2 City Postcode

Reimbursement claims paid to member directly. Please provide your bank account number*

This section is about the patient information.

Patient First Name*

Patient Last Name*

Patient's Date of Birth*

Is this an ACC Claim?*

Yes - We do not cover ACC claims

No - Please proceed

This section is about the costs you are claiming back.

Medical Treatment Provider 1

Name of Provider*

Date of Treatment*

Reason for Treatment*

Amount Claimed*

Attach Receipts

Drop files here or

Max. file size: 10 MB.

Medical Treatment Provider 2

Name of Provider

Date of Treatment

Reason for Treatment

Amount Claimed

Attach Receipts

Drop files here or

Max. file size: 10 MB.

Medical Treatment Provider 3

Name of Provider

Date of Treatment

Reason for Treatment

Amount Claimed

Attach Receipts

Drop files here or

Max. file size: 10 MB.

PRIVACY STATEMENT

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Contact Healthcare99

Healthcare99 Claim form – Out of Hospital

Member

This section is about the patient information.

This section is about the costs you are claiming back.

PRIVACY STATEMENT

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