National Private Patient Claim Form printable pdf download

3. HOSPITAL ACCOMMODATION DETAILS (To be completed by Hospital: please see overleaf for codes.)

NATIONAL PRIVATE PATIENT HOSPITAL CLAIM FORM

Admission Date:

Separation Date:

Private Health Fund

Hospital

Admission Accomm.

Date

Discharge

Days

Payment Type

Amount

Code

From

Code

Claimed

Code

Charged

Hospital

Other:

Provider Number

Record Number

Other:

1. PATIENT / FUND MEMBERSHIP DETAILS (Please print and insert ticks ( ) in boxes)

Other:

Family Name of Patient

Mr/Mrs/Miss/Ms

Other:

Given Names of Patient

Same Day Patients Only

Time in Theatre

Membership Number

Level of Cover

(Please tick ( ) boxes below)

(ALL EPISODES – 24 hr)

Relationship of

Patient’s

From

Admission

Separation

Same Day

Patient to Member

Date of Birth

Age

Time (24hr)

Band (1-4)

From

Family Name of Member

Mr/Mrs/Miss/Ms

Anaesthetic:

None

Local

Intravenous

Regional

General

From

Theatre/MBS

Other Services

(*Principal MBS first)

Given Names of Member

MBS Item

Date of Service

Amount Charged

Code

Date of Service

Number

Amount Charged

Residential Address

of Member

Postcode

Is this a permanent address? Yes

Telephone: Home (

)

Work (

)

Mobile

Certificates Attached:

Same Day Certification

Adding a newborn child to your family membership: Sex

Date of Birth

Please tick ( ):

Acute

Psych.

Rehab.

ICU

NICU

Pt. Election

(See Section 4 overleaf)

Family Name

Given Names

Diagnoses / Procedures / Other Details

Full name of Admitting Medical Practitioner:

DRG

DRG VERSION

PRINCIPAL DIAGNOSIS ICD-10-AM

Additional

2. DECLARATION CONCERNING CLAIM (The accurate answers to these questions are an essential part of this claim)

Diagnoses

ICD-10-AM

Patient/Guardian to complete (please tick ( ) below)

Yes

Do you have entitlement to claim compensation or damages (including previous settlements)?

Have you lodged a claim for compensation or damages?

Did the injury or condition occur at work, going to or from work or as a result of being at work?

Did the hospitalisation result from a motor vehicle accident?

Procedure

Codes

Did the hospitalisation result from any other type of accident?

ICD-10-AM

Does the patient have an entitlement to free treatment under Australian Veterans’ legislation?

(*Principal

Procedure first)

Is the patient a full-time student dependant over 17 years and under 25 years?

If yes, name of educational institution:

Infant/Neonate

Age in

Urgency of

Mode of

Source of

Transfer In

Date patient was first aware of symptoms:

Date patient first consulted a doctor for symptoms:

Weight

Days

Admission

Separation

Referral

Were the financial implications of your hospital charges explained prior to admission?

Have you signed an Election Form to elect to be treated as a private patient?

(PUBLIC HOSPITAL PATIENTS ONLY)

Care Type

Non-Acute

Total Leave

ICU Hours

MV Hours

Transfer Out

Length

Days

I hereby declare and warrant that all the above information provided in connection with this claim is true and correct.

of Stay

I authorise the hospital, or any other authorities concerned with this hospitalisation, injury, disease or ailment, or the

Same Day Status

Mental Health

Inter-Hospital

Unplanned Theatre Visit

Provider No. of Hospital

treatment or diagnosis, to supply all information, including Hospital Casemix Protocol information as required by the

Legal Status

Contracted Patient

During Episode:

Transferred From:

Transferred To:

Federal Government, to the private health fund for the purpose of providing private health insurance in accordance

Yes

with the fund’s privacy policy.

I certify the above information is true and correct according to our records for this period of hospitalisation.The hospital authorises

I authorise my health fund to pay benefits directly to the hospital.

the fund or its agent to inspect all records applicable to the patient for the purpose of determining appropriate benefits.

Patient’s/

Authorising Hospital

Guardian’s Signature:

Date:

Officer’s Signature:

Date:

National Private Patient Claim Form

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