Pre-approval Form PH 01

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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