Claim form - Defence Health

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					Applicant Surname


Applicant First name                                                             Title/Rank
                                                                                                                                 Defence Health Limited
                                                                                                                                 ABN 80 008 629 481 AFSL 313890
Address                                                                                                                          PO Box 7518 Melbourne VIC 8004
                                                                                                                                 Freecall 1800 335 425
                                                                                                                                 Facsimile 1300 665 096
Suburb                                                            State          Postcode                                        www.defencehealth.com.au
                                                                                                                                 info@defencehealth.com.au


Daytime phone                    Email
                                                                                                                   Member No



    A   Health benefits claim form
              PLEASE COMPLETE IN BLACK PEN AND IN BLOCK LETTERS WITHIN THE BOXES PROVIDED. ORIGINAL ACCOUNTS AND RECEIPTS MUST BE ATTACHED.


Given name and                  Date of         Date of         Type of              Name of practitioner                             Account       Name of school*
initial of patient              birth           service         service              (include practice suburb)                        Paid          if aged 21 - 25

eg. Peter A                     04/09/69        18/11/05        Physio               Andrew Black - Brighton                          Yes/No        Monash Uni




Benefits to dependants aged 21-25 are only payable to full-time students attending school, university or college.
*




    B   In-hospital medical claim
Please check with your doctor’s office as to whether the account is an Access Gap Cover claim or a standard medical gap claim.
If Access Gap Cover - send the claim form directly to us without going to Medicare. We will pay the combined Medicare and health fund benefit.
If a standard medical gap claim - submit the doctors account to Medicare first, then send the resulting Medicare Statement to Defence Health.
Name of hospital                                                          Admitted            /          /              Discharged              /            /
Adding a new born baby?  Daughter                Son      Given names                                                         DOB             /            /


    C   Payment
• If you have already paid your health service provider your benefit will be remitted directly into your previously registered Direct Claims Payment
  bank, building society or credit union account. You can register, check or alter your direct credit account online at www.defencehealth.com.au
  or by calling us on 1800 335 425.
• A cheque to the provider will be drawn for any unpaid accounts.
• A cheque to the member will be drawn if you do not have a registered Direct Claims Payment bank, building society or credit union account.
• If you are an overseas Defence Force member please tick  to have your benefit remitted into your pay through DEFPAC.

    D   Declaration
Are any of the services claimed related to an accident, illness or injury which has, or may, result in payment of compensation or
damages from another source eg. Workers Compensation, Transport Accident, Third Party or any other source?  No  Yes
                                                                                                                                                                 *AHBCA009*



If yes, please complete an accident questionnaire. You can download one from www.defencehealth.com.au or contact our member
service line on 1800 335 425 to have one posted to you.
                                                                                                                                                                        * A HB CA 009 *




I declare that I have incurred the expenses in this claim and to the best of my knowledge, the information supplied is true and correct.
I authorise Defence Health Limited to obtain such information as is necessary from the provider to verify or audit this claim.



Signature                                                                                         Date


        The Defence Health Privacy Policy can be viewed at www.defencehealth.com.au or call our member service line on 1800 335 425 to have one posted to you.

				
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posted:12/22/2011
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