Fillable Medical Certificate Form - Bupa printable pdf download

M E D I C A L C E R T I F I C AT E

1. Before completing this certificate, see the back page for important information about pre-existing medical conditions.

2. Please complete all details that are relevant to you, read the declaration and sign all the relevant signature panels.

3. Mail your completed certificate (marked Private and Confidential) to the address listed below, or alternatively fax it

to 1300 303 548.

SECTION 1: Your details – to be completed by member/patient

Membership number

Cover

Mr/Mrs

Surname

First name/s

Miss/Ms

Mr/Mrs

Patient’s surname

First name/s

Miss/Ms

Date of birth

Nature of ailment, illness or condition

Claim details (where applicable)

Name of hospital

Period of hospitalisation from

Number of days

Patient authority

I authorise all medical practitioners whom I consulted for the above ailment, illness or condition to provide Bupa with any personal and medical

information relating to my medical history and any other additional information as may be required for the purpose of determining this claim.

Patient’s (or Guardian’s if applicable) signature

Date

SECTION 2: Certificate – to be completed by treating medical practitioner

1. How long have you been the treating medical practitioner for the above patient? Years

Months

Weeks

Days

2. How many times has the above patient consulted you for professional advice over the past twelve months?

3. Did any of the consultations provided over the past twelve months exhibit signs or symptoms which could have been indicative of the patient’s

current condition? Yes

If Yes, please give details

4. I certify that in my opinion

(Patient’s full name)

first consulted me with signs or symptoms

consistent with

(nature of current illness or condition)

(date)

Years

Months

and in my professional opinion such signs and symptoms

had been in evidence prior to this date for a period of

Weeks

Days

5. Describe the nature of presenting symptoms

6. Has the patient ever suffered from an episode of similar symptoms (including similar symptoms of lesser severity) or has this diagnosis

been made in the past? Yes

If Yes, when?

7. Is the condition acute or chronic?

8. Final diagnosis of ailment, illness or condition(s) which determined reason for hospitalisation

9. Please add any other relevant information or comments

Medical practitioner’s name

Qualifications

Phone number

Fax number

Are you primarily a (please select one) ? GP

specialist

surgeon

Medical practitioner’s signature

Date

The fee, if any, for the completion of the above certificate and any additional information is not chargeable to the Fund.

Mail to Bupa Hospital Claims Department Private and Confidential Reply Paid 990 ADELAIDE SA 5001

1/2

10239-04-13S

Bupa Australia Pty Ltd

ABN 81 000 057 590

Medical Certificate Form - Bupa

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