Sample Claim Form (Page 2 of 2) in pdf

Claim form

Complete this section if you saw a doctor

Did you know?

or went to hospital

Direct Billing Medical Providers

Allianz Global Assistance has an extensive network of medical providers around

Have you had this or a related condition before?

yes

Australia – show your valid membership card and you do not have to make

If yes, please provide details (dates, name & address of treating

a claim. The bill is sent directly to Allianz Global Assistance (some medical

providers may charge a co-payment which cannot be claimed). Find your local

doctors/s, treatment etc):

Direct Billing Medical Providers online at

Online Services –

Visit our website to:

•

Renew your policy

•

Order replacement membership cards

•

View our helpful information video

•

Read health and wellbeing information

24 Hour Emergency Helpline – 1800 814 781

Payment to Australian bank account by EFT

Emergency access to medical, legal and interpreting services

(Electronic Funds Transfer)

Please provide correct bank account details to ensure prompt payment

Protection of your personal information

(only complete if you have already paid the account and have attached

original tax invoices and receipts). If correct bank details are not

We collect your personal information

provided, a cheque will be sent to your Australian postal address.

To arrange, manage, and provide your OVHC health cover, we (AGA

Assistance Australia Pty Ltd trading as Allianz Global Assistance as agent

Name of financial institution:

for the insurer, Lysaght Peoplecare Limited) collect, use, and disclose your

personal information including sensitive information. We collect it from

Name of account holder:

you as well as others including (but not limited to) your family members,

travelling companions, universities, other educational institutions, Government

BSB number (6 digits):

Departments including those responsible for administering visa requirements

for overseas visitors and students, doctors, hospitals, medical providers and

Account number (up to 9 digits):

others we consider necessary. We disclose your personal information to various

persons and entities including those mentioned above as well as to others

Declaration

that assist us to provide our services and to carry out our normal business

functions and processes including to claims investigators and for legal recovery

purposes. For example, we collect, use, and disclose your name, address, date

I declare that all statements and particulars contained on this claim

of birth, medical and other sensitive information for these purposes.

form are true and correct.

We also use and disclose it so as to comply with regulatory requirements.

Allianz Global Assistance

I authorise

to contact the hospital or

When you make a claim under your policy, you agree and consent to us

provider of any service for further clarification of details relating to

collecting, using and disclosing your personal information (including sensitive

information) as set out above including to your healthcare provider.

this claim if necessary.

For more information about our handling of your personal information,

Signature:

including details about access, correction and complaints, please contact

our Privacy Officer on (07) 3305 7000 or refer to our corporate privacy policy

available on request or on the web at

Date:

_ _ /_ _ /_ _ _ _

Office use only

Incident #:

Allianz Global Assistance will endeavour to process your claim within

10 working days of receiving a completed claim form and all original

documents.

Please return completed form to:

Allianz Global Assistance

Locked Bag 3004, Toowong QLD 4066

Phone:

1300 727 193

Fax:

+61 7 3305 7316

Email:

.au

Allianz Global Assistance Overseas Visitors Health Cover is managed by AGA Assistance Australia Pty Ltd ABN 52 097 227 177. Lysaght Peoplecare Limited ABN 95 087 648 753,

a private health insurer under the Private Health Insurance Act 2007 (Cth) is the underwriter of Allianz Global Assistance Overseas Visitors Health Cover policies.

Sample Claim Form Page 2

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