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

Healthcare99

Contact Healthcare99

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

Healthcare99 Claim form – Out of Hospital

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

Tick this box to agree*

I agree to the privacy statement and confirm it is true and correct

This document collects personal information about you so the New Zealand Firefighters Welfare Society can consider your claim.

The information is received and held by the New Zealand Firefighters Welfare Society, PO Box 30777 Lower Hutt 5040.

You may request access to, and correction of, this information according to the provisions of the Privacy Act 2020.

I declare to the best of my knowledge the details given in this claim form are true.

I agree that the New Zealand Fire Fighters Welfare Society 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 the New Zealand Firefighters Welfare Society, 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).
By checking this box you agree to the privacy statement above.

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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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