Treatment Guarantee Form (Page 2 of 2) in pdf

TREATMENT DETAILS

to be fully completed by the Medical Provider

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If additional treatment is required, Allianz Worldwide Care must be notified.

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Please note that all invoices should be submitted within 60 days of patient discharge. Where special arrangements have been agreed between us and the medical

provider, these arrangements will apply.

Condition

Description of the condition, signs and symptoms

Underlying cause

(if known)

Date this condition was first diagnosed

Date of first attendance for this condition

On what date would the first onset of symptoms have been apparent to the patient?

Diagnosis

(if unknown, please state provisional diagnosis)

ICD9/10

DSM-IV

DRG

Please also provide the following details for maternity cases

Date pregnancy confirmed by doctor

Expected or actual date of delivery

Is birth of a single baby expected? Yes

If No, is the pregnancy a result of medically assisted reproduction other than artificial insemination? Yes

Delivery method

Treatment

Planned procedure/treatment

Planned admission date

For treatment in the USA/UK

CPT code(s)

CCSD code(s)

Description

Costs

For treatment in Germany (DRG) please confirm Base Price (Basisfallpreis)

Estimated length of stay

night(s)

/ day(s)

(tick as appropriate)

Is a package price being offered? Yes

If Yes, please state the price offered incl. currency:

If No, please provide a breakdown of estimated costs:

Hospital charges

Physician/anaesthetist fees

Total estimated costs incl. currency:

Medical provider details

Hospital/facility name

Address

(including country)

(mandatory)

Telephone

(Country code)

(Area code)

Fax

(mandatory)

(Country code)

(Area code)

Referring physician

Attending/admitting physician

Name

(mandatory)

Telephone

(incl. country and area codes)

Fax

(mandatory, incl. country and area codes)

Please sign and authenticate with an official stamp.

I confirm that all the details given in this form are, to the best of my knowledge, true, accurate and complete.

Official stamp of medical provider

Doctor’s signature

Date

Please send this fully completed Treatment Guarantee Form at least five working days prior to treatment by:

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Scan and email to: or

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Fax to: + 353 1 653 1780 or

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Post to: Medical Services Department, Allianz Worldwide Care, 15 Joyce Way, Park West Business Campus, Nangor Road, Dublin 12, Ireland.

We advise that you keep copies of all correspondence with us as we cannot be held responsible for correspondence that does not reach us for any reason that is outside of our

reasonable control.

If you have any queries, please contact our Helpline on: + 353 1 630 1301 or email:

For our latest list of toll-free numbers, please visit: