Group Claim Form (Page 2 of 2) in pdf

Sections 5 and 6 are to be completed by the treating doctor unless detailed in the supporting documentation (e.g. receipts or invoices).

5 Medical provider’s details

Name of doctor/specialist

Qualifications/credentials

Name of hospital/clinic

Address

Telephone number

(incl. country code and area code)

Fax number

(incl. country code and area code)

Applicable to physiotherapy/psychotherapy claims only. Please provide full referral details:

Name of referring physician

Telephone number

Date of referral

(incl. country code and area code)

(dd/mm/yy)

6 Medical details

Official stamp of medical provider

Please sign and authenticate with an official stamp.

Doctor’s signature

Date

(dd/mm/yy)

7 Data Protection and release of medical records

References to information includes personal information given by you to us, in your

Representation and consent: By signing this form you confirm that you have the

Application, Claim or Treatment Guarantee Form and/or supporting documents/

authority to act on behalf of your dependants in respect of all personal information

information we collect in connection with products or services we provide. Allianz

you provide to us, and that you consent to the disclosure, processing, usage and

Worldwide Care, part of the Allianz Group, is the data controller for this information.

retention of this information in relation to yourself and on behalf of your dependants.

Uses: Personal information may be used for insurance administration (e.g.

Access: You have the right to request and receive a copy of your personal data held by

underwriting, claims handling, fraud prevention). We may use third parties to process

us. If you wish to do this, please write to the Data Protection Officer at the address

data on our behalf. Such processing, which may take place outside the European

provided on this form or via

Economic Area (EEA), is subject to contractual restrictions regarding confidentiality

Call recording: Calls to our Helpline will be recorded and may be monitored for

and security in line with Data Protection obligations.

training, quality and regulatory purposes.

Sensitive data: We need to collect sensitive data relating to you (e.g. health details),

I certify that to the best of my knowledge, this Claim Form does not contain any false,

to assess insurance terms and/or administer claims.

misleading or incomplete information. I understand that in the event that this claim is

Disclosure: We may share your information with our agents, members of the Allianz

found to be fraudulent, in whole or in part, the contract will be cancelled from the date

Group, other insurers and their agents, service providers, any intermediary acting on

of discovery of the fraudulent event and I may be liable to prosecution.

your behalf or governing/regulatory bodies (of which we are a member or by which

I agree to waive any rights that I may have to medical secrecy/confidentiality in respect

we are governed). In certain circumstances, we may use private investigators to

of my medical information and I authorise my medical practitioner, health professional

investigate a claim you have submitted.

or other relevant medical establishment to provide relevant medical information

Retention: We are obliged to retain your records for six years from the date the

relating to me, if requested by Allianz Worldwide Care, its medical advisers, its

insurance relationship ends. We will not retain your data for longer than necessary and

appointed representatives, or to any third party expert(s) in case of disputes, subject to

will hold it only for the purposes for which it was obtained.

any legal restrictions which may apply.

If a minor was treated, a parent or guardian should sign this section.

Patient’s signature

Date

(dd/mm/yy)

8 Third party authorisation

INSERT NAME OF THIRD PARTY

As the claimant, I hereby authorise

to act on my behalf and on behalf of any dependants named on this form (where applicable), in relation to the administration of this claim which may include the disclosure of sensitive

medical information.

Claimant’s signature

Date

(dd/mm/yy)

Claimant’s printed name

It is your responsibility to retain any original supporting documentation (e.g. medical receipts) where copies are submitted to us, as we reserve the right to request original supporting documentation/

receipts up to 12 months after claims settlement for auditing purposes. We also reserve the right to request a proof of payment by you (e.g. bank or credit card statement) in respect of your medical

receipts. 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.

Please send your fully completed Claim Form(s) with invoices/receipts as follows:

By email to: , by fax to: + 353 1 645 4033, or by post to: Claims Department, Allianz Worldwide Care,

15 Joyce Way, Park West Business Campus, Nangor Road, Dublin 12, Ireland.

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: