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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
*
Day
Month
Year
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
*
Day
Month
Year
Reason for Treatment
*
Amount Claimed
*
Attach Receipts
Drop files here or
Select files
Max. file size: 10 MB.
Medical Treatment Provider 2
Name of Provider
Date of Treatment
Day
Month
Year
Reason for Treatment
Amount Claimed
Attach Receipts
Drop files here or
Select files
Max. file size: 10 MB.
Medical Treatment Provider 3
Name of Provider
Date of Treatment
Day
Month
Year
Reason for Treatment
Amount Claimed
Attach Receipts
Drop files here or
Select files
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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0800 65 34 73
Join Today
Membership Support
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AON – Get a Quote
The Wolf Was Not Sleeping
External Support Agencies
Holiday/Convalescent Homes
Book Online
NZ Police Holiday Homes
Army Leave Centres
Healthcare99
Join Here
Plans
Option A
Option B
Costs
Option A
Option B
Terms & Conditions
Making a Claim
Pre-approval of Claims
Reimbursement of Claims
Forms
Frequently Asked Questions
Contact Healthcare99
Resources
Forms
Shift Calendars
NZFFWS AGMs
2023 AGM
2022 AGM
2021 AGM
2019 AGM
Healthcare99 AGMs
2023 AGM
2021 AGM
2020 AGM
2018 AGM
2017 AGM
2015 AGM
Society Rules
Station Folder
Privacy Policy
Board Nominations
External Support Agencies
News
Past Newsletters
News Archive (Pre-2020)
About Us
Contact Us
Donate
PORTAL