Dental CashPlan Plus claim form
OFFICE USE ONLY
Please quote your policy number on all correspondence
Policy number:
A Policyholder details
Title: Address: First name: Surname:
● All claims should be submitted within 30 days of you paying for treatment. ● Only one patient per claim form. ● Please refer to your Policy Booklet, which will confirm the benefit categories and levels under which to claim. ● Your claim cannot be processed without a receipt confirming either the NHS treatment Band details and cost for reimbursement for NHS treatment, or an itemised receipt confirming all non-NHS injury or emergency treatment being claimed. ● Please attach your receipt securely to the claim form.
Amount paid
Postcode: Daytime telephone:
Date of birth: Evening telephone:
Patient details (if not policyholder)
Title: Date of birth: First name: Surname:
Payment details
Please tick to whom the cheque should be made payable:
Policyholder
Patient
B Treating dentist’s details
Treating dentist’s name: Treating dentist’s address:
To be completed by the patient or the policyholder
Postcode:
Telephone number:
C NHS treatment details
To be completed by the patient or the policyholder Date of first appointment Date of final appointment
NHS band for course of treatment
● The claim form must be signed by the policyholder. ● Incomplete claim forms will be returned. ● All payments are made by cheque in £ sterling.
Band One
Including examination, diagnosis and preventive advice, x-rays, scale and polish, and planning for further treatment or an emergency appointment. £
Band Two
Including all necessary treatment covered by Band One PLUS added treatment such as fillings, root canal treatment or extractions. £
Band Three
Including all necessary treatment covered by Bands One and Two PLUS more complex procedures such as crowns, dentures or bridges. £
Other (please specify):
D Injury/emergency treatment
Date of incident: How did the incident occur? Date of treatment:
OFFICE USE ONLY
DPA checked by:
Date:
Type of treatment:
DPA amended by:
Cost: Was the treatment overseas? Yes No
Date:
Hospital benefit
Address checked by:
Date of admission: Reason for stay: Date of discharge:
Date:
Address amended by:
Total claim value
£
Date:
Declaration
I declare I am the policyholder and that the patient is covered by my policy. I wish to make a claim on my policy and declare that all the particulars given above are, to the best of my knowledge, true and correct. I confirm that the patient consents to AXA PPP healthcare processing the particulars of this form and in any medical reports or health records that may be requested.
Once you have completed this form please send it to: Dental CashPlan Plus - Claims, AXA PPP healthcare, Victoria Road, Winchester, SO23 7RG.
Data Protection Act – you will see this sign where we ask you to give personal information. To set up and administer your policy we will hold and use information about you, and any family members covered by your policy, supplied by you or those family members and by medical providers. We may send it in confidence for processing to other companies in the AXA Group (or companies acting on our instructions) including those located outside the European Economic Area. By signing this form you and any family members covered by your policy consent to such use of this personal data. You may be contacted by post, telephone or electronically if appropriate. If you do not wish us to do this please tick the appropriate box(es). AXA may send you details of our other products and services. To enable them to send you details of their services we may also share some of your details with other AXA Group companies based within the European Economic Area and with other carefully selected companies based within the European Economic Area .
Policyholder’s signature
Date:
AXA PPP healthcare limited (Company Number 3148119). AXA PPP healthcare is authorised and regulated by the Financial Services Authority. Registered office: 5 Old Broad Street, London EC2N 1AD, United Kingdom. CPP02 07/07