Form Frm-Cf - Claim Form (Page 4 of 4) in pdf

7 Data Protection and release of medical records

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

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

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

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

documents/information we collect in connection with products or services we

address provided on this form or via

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

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

this information.

training, quality and regulatory purposes.

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

Direct marketing: Personal data collected by us will not be used to contact you for

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

direct marketing purposes, unless you have consented to this.

process data on our behalf. Such processing is subject to contractual restrictions

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

regarding confidentiality and security in line with Data Protection obligations.

false, misleading or incomplete information. I understand that in the event that

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

this claim is found to be fraudulent, in whole or in part, the contract will be

details), to assess insurance terms and/or administer claims.

cancelled from the date of discovery of the fraudulent event and I may be liable to

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

prosecution.

Allianz Group, other insurers and their agents, service providers, any intermediary

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

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

respect of my medical information and I authorize my medical practitioner, health

or by which we are governed). In certain circumstances, we may use private

professional or other relevant medical establishment to provide relevant medical

investigators to investigate a claim you have submitted.

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

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

advisers, its appointed representatives, or to any third party expert(s) in case of

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

disputes, subject to any legal restrictions which may apply.

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

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

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

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

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

dependents.

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

Patient’s signature

Date

(DD/MM/YY)

8 Third party authorization

As the claimant, I hereby authorize

INSERT NAME OF THIRD PARTY

to act for and on my behalf and on behalf of any dependents 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

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

Scan and email to:

Fax to:

+ 353 1 645 4033

Post to:

Claims Department, Allianz Worldwide Care, 15 Joyce Way, Park West Business Campus, Nangor Road,

Dublin 12, Ireland

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 contact our Helpline if you have any queries: +353 1 517 6988 or email: .

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

Important - please check the following:

All receipts, invoices and prescriptions are included.

The diagnosis has been confirmed and is either stated on the Claim Form or on the

The Claim Form is completed in full.

invoice(s).

The declarations are signed and dated.

If you have changed your contact details, please let us know on the Claim Form.

Allianz Worldwide Care SA. QFC Branch address: Office 604-C, 6th floor, Jaidah Square Building, 63 Airport Road, Zone 27, Umm Ghuwailina, P.O. Box 31316, Doha, Qatar.

Phone: +974 4031 8444. Fax: +974 4031 8484. Website:

Authorized by the Qatar Financial Centre Regulatory Authority. Allianz Worldwide Care SA is incorporated in France.