Form Cf 11/04 - Claim Form. (Page 2 of 2) in pdf

Form Cf 11/04 - Claim Form. Page 2

Sections 5 and 6 to be completed by treating doctor in BLOCK CAPITALS unless your invoices contain details of the diagnoses as

well as the nature of your treatment.

5. Medical provider information.

Name of doctor/specialist

Qualifications/credentials

Name of hospital/clinic

Address

Phone

Fax

6. Medical information.

Has Treatment Guarantee been obtained?

Yes

Indicate type of treatment received:

Elective

Emergency

Indicate type of condition:

Acute

Chronic

Acute episode of chronic

Please provide full details of the medical condition requiring treatment, including ICD code/DSM-IV

d d

m m

y y

On what date did the patient first present these symptoms to you?

Date

(dd/mm/yy)

Prior to consulting you, when did the patient first notice signs

d d

m m

y y

or symptoms of this medical condition?

Date

(dd/mm/yy)

Are you aware of any treatment given for this or any related illness in the past?

Yes

If yes, please provide details

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

Name of referring physician

Telephone number

d d

m m

y y

Date of referral

Applicable to dental treatment claims only.

Was the patient suffering from dental pain at the time he/she visited you for treatment?

Yes

Doctor signature

d d

m m

y y

Pacific Prime International

Date

(dd/mm/yy)

STAMP

The confidentiality of patient and member information is of paramount concern to Allianz Worldwide Care. Allianz Worldwide Care fully complies

with European Data Protection Legislation and International Medical Confidentiality Guidelines. You have a right to access the personal data that is

held about you. You also have the right to request that we amend or delete any information which you believe is inaccurate or out of date.

Form Cf 11/04 - Claim Form. Page 2

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