Claim Form Medicare International Page 2
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212. Are further accounts to be submitted? If so please give details:
16.
I authorise (1) the release of any medical information necessary to
13. Is this a continuation of previous or current treatment for which
process this claim and (2) the processing of any medical information
you have already claimed under this policy? If yes, please give
or other personal data provided by me or by my physician/dentist and
details, including claim reference number:
the disclosure of such information to underwriters via claims handling
agents and, where relevant to loss adjusters for the purpose of this
claim. I declare that I have not received medical advice or treatment or
experienced symptoms for the illness/injury for which I am now claiming
within two years prior to the first date of my insurance cover under this
policy. (This does not apply if you are insured under a Group Plan where
14. Please provide the name and address of your usual
the Pre-Existing Condition exclusion has been waived). To the best of my
General Physician:
knowledge all the afore mentioned particulars are true.
Signature of Insured Person or Legal Representative:
Date:
15. Please provide details or other doctors and or surgeons who
have treated you for this or related conditions
THE SECTION(S) BELOW MUST BE COMPLETED BY THE
TREATING PHYSICIAN/DENTIST
Section C – Medical Information
TO BE COMPLETED BY TREATING PHYSICIAN
17. Please state the date on which the patient first consulted you
22. Please give a history of this or any related or similar conditions
for this or any similar or related condition:
with dates on which any previous treatment or investigation
took place:
18. Please describe the symptoms presented and state when
symptoms first occurred:
23. If all or a part of the treatment was in respect of elective
cosmetic surgery, please indicate the amount or the proportion
of the costs involved:
19. Please give name and address of the referring Physician:
Postcode:
24. Have you any reason to believe that the treatment for the same
Telephone:
or similar condition has been given previously? If yes, give details:
Facsimile:
Email:
20. Please give your diagnosis of the illness/injury:
25. In respect of claims for maternity care please state the expected
delivery date and the date on which the patient first consulted
you for this pregnancy:
21. Is the condition likely to be considered congenital or a birth
defect? If so please provide details:
Signature of treating physician:
Please state your qualifications
Section D – Routine Dental Treatment Information
TO BE COMPLETED BY THE TREATING DENTIST
a.
Has the patient attended for routine check-up in the past
d.
Please print your name and address:
12 months and was all necessary treatment concluded?
Postcode:
Telephone number:
b.
In your opinion has the patient maintained good dental hygiene?
Fax number:
Email address:
Signature of treating dentist:
c.
Please describe dental necessity for this claim?
Please state your qualifications
MediCare International Limited is an Appointed Representative of APRIL Medibroker Limited which is authorised and regulated by the Financial Conduct Authority.
SEPTEMBER 2013
Registered Office: Minster House, 42 Mincing Lane, London EC3R 7AE, United Kingdom. Registered in England No. 7261287.
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Parent category: Medical