Pre-approval Form PH 01

Healthcare99

Contact Healthcare99

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

Member Details

First Name*

Last Name*

Email*

Patient Details

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

This section is about your claim information.

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

PRIVACY STATEMENT*

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.

CAPTCHA

Contact Healthcare99