Claim Checklist by iij11860

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									Claim Checklist

     Please read the following information before submitting a claim form to Denplan.



     3 Claiming Checklist
            In order for your claim to go through successfully please make sure you have done the following:

     3      fill out all the relevant white boxes on the claim form

     3      make sure the policyholder signs and dates the claim form NOT the patient or the dentist

     3      use one claim form per person

     3      attach an itemised receipt showing proof of payment and a breakdown of the treatment

     3      If you have received NHS treatment or emergency treatment, please make sure this is clearly stated on your itemised receipt

     Please note: We cannot accept a treatment plan and if any of the above has not been completed, your claim may be returned or
     the assessment delayed. If the receipt is not written in English, your claim may take longer to assess due to translation, so please bear with
     us. Please make sure you submit your claim form within 60 days of treatment. Denplan will process your claim and send payment within five
     working days (providing we recieve full information about your treatment).



     How your receipt for treatment SHOULD look:
                                                                                                                                                   This is an example
                                           Statement of Accounts as at 27/11/2008                                                                of an itemised receipt.
                                                                                                                                                    You can ask your
     Date                                                                                                        Debit               Credit         dentist for one of
     30/10/08        1                              Anterior Composite Restoration                               60.00                          these, it clearly advises
     30/10/08        1                              Splint Impression                                            197.50                            us what treatment
     30/10/08        Receipt       13449                                                                                             257.50      you have had and will
     27/10/08        1                              Splint Fitting                                               197.50
                                                                                                                                                ensure we process your
                                                                                                                                                claim correctly. (Please
     27/10/08        Receipt       13546                                                                                             197.50
                                                            Total Owing £0.00                                                                   note: we cannot accept
                                                                                                                                                    a treatment plan)




  How your receipt for treatment SHOULD NOT look:

                                                                     Receipt
                                                                                                                                                   This is an example
     Charges                                                                                                                                     of a receipt which has
                                                    TOTAL                               £0.00                                                   NOT been itemised. This
                                                                                                                                                would cause delay in the
     Payments                                                                                                                                   processing of your claim
                                                    Visa                             £200.00                                                    form. It does not tell us
                                                    TOTAL                            £200.00                                                    what the treatment is for
                                                                                                                                                 or when it took place.
                                                    Credit Balance                   £200.00

                                                           Received with thanks



Further information can be found on our website www.denplan.co.uk
Up to date product information and literature can be found at the following link: www.denplan.co.uk/company-plans
If you would like further information on how to claim or would like to download a claim form please use the following link:
www.denplan.co.uk/company-plans/employees/how-to-claim.aspx the claim form link for a PDF can be found on the right
hand side should you need a claim form immediately.


Denplan Limited, Denplan Court, Victoria Road, Winchester, SO23 7RG, UK.
Tel: +44 (0) 1962 828000. Fax: +44 (0) 1962 840846. Email: denplan@denplan.co.uk
Registered in England No. 1981238. Registered address 5 Old Broad Street, London, EC2N 1AD, UK.
Denplan Limited is an Appointed Representative of AXA PPP healthcare Limited which is authorised and regulated by the
                                                                                                                                                                            CORP241 02-09




Financial Services Authority. This information can be checked by visiting the FSA register which is on their website: www.fsa.gov.uk/register
or by contacting the FSA on 0845 606 1234. Denplan Limited is regulated by the Jersey Financial Services Commission. This policy is
underwritten by AXA PPP healthcare Limited. Denplan Limited only offers dental insurance from AXA PPP healthcare Limited and is a member
of the AXA UK plc group of companies of which AXA PPP healthcare is a member. Telephone calls may be recorded for security, regulatory
and training reasons as well as monitored under our quality control procedures.
                                                                      Office use only

Denplan Claim Form                                                    CR
                                                                      P1:
                                                                      P2:
                                                                                                                                                 A:

                                                                      P3:                CCD:         Date:               Amount:
                                                                                                                                                S:

   Once you have completed this form please post it to: Denplan Corporate, Denplan Court, Victoria Road, Winchester SO23 7RG.
   For further information about claiming please visit: www.denplan.co.uk If you have any queries, please do not
   hesitate to contact us: Call: 0800 838 951 or Email: corporate@denplan.co.uk (Lines are open 8.00am to 5.30pm Monday to Thursday and
   8.00am to 4.30pm Friday, calls may be recorded).



   3 Claiming Checklist
         In order for your claim to go through successfully please make sure you have done the following:
         fill out all the relevant white boxes
         make sure the policyholder signs and dates the claim form NOT the patient or the dentist
         use one claim form per person
         attach an itemised receipt showing proof of payment and a breakdown of the treatment
         If you have received NHS treatment or emergency treatment, please make sure this is clearly stated on your itemised receipt

   Please note: We cannot accept a treatment plan and if any of the above has not been completed, your claim may be returned or the
   assessment delayed. If the receipt is not written in English, your claim may take longer to assess due to translation, so please bear with us. Please
   make sure you submit your claim form within 60 days of treatment. Denplan will process your claim and send payment within five working days
   (providing we receive full information about your treatment).


Policyholder/Patient details

Policy number:                                                              Company name:

Policyholder details (employee of the company):
Date of birth:        DD MM YY                                                           Title:

First name:                                                                         Surname:

Address:



Postcode:                                    Email:   (Personal)

Phone number: (Daytime)                                                                           (Evening)

Patient details (if different from the policyholder):
Date of birth:        DD MM YY                                                           Title:

First name:                                                                         Surname:


Please tick who the cheque should be made payable to:                                                     Policyholder:                  Patient:


Routine/restorative treatment details
Please list all treatment details, e.g. examination, hygiene treatment, x-ray, filling, inlay, crown, bridge, denture, etc.
                                                                                 NHS       Private    Overseas Date                       Amount Paid

  e.g examination (band one)                                                      3                                 01 04 08              £16.20




                                                                                                         Total Amount Paid:               £0.00
  Dental injury/emergency treatment details
 Please tick whether it was an dental injury or emergency treatment:                                                                      Injury                      Emergency

Date of dental injury/emergency:                                DD MM YY

 What type of treatment did you receive:                                                      NHS                                       Private                         Overseas

 Treatment details:




 Call out fees:            Time:                                                          Date of treatment:             DD MM YY                        Amount Paid:

                                                                                              Date of call out:          DD MM YY                        Amount Paid:

                                                                                                                                                   Total Amount Paid:   £0.00

 Please tick the below if they apply to you:
 If the injury/emergency was a result of a contact sport:                               Yes            No

 If yes, were you wearing a mouth guard:                                                Yes            No


  Other treatment details

 Hospital cash benefit:                            Date of admission:               DD MM YY                               Date of discharge:            DD MM YY

 Mouth cancer cover:                                Date of diagnosis:              DD MM YY                               Date of treatment:            DD MM YY



  Treating dentist’s details
Please inform your dentist if you are claiming through Denplan. This will enable them, to disclose important information to us
regarding treament details and your dental records. This will help your claims process go through quicker.
 Dentist’s name:

 Practice name:

 Address:



 Postcode:                                                                                         Phone number:



  Declaration
  I declare that I am the policyholder.

  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 Denplan processing the particulars on this form and in any medical reports or health records that may be requested.

      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) below.
  Denplan Limited 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 signature:                       Please sign after printing                                                       Date:              D   D    M    M       Y    Y




Denplan Limited, Denplan Court, Victoria Road, Winchester, SO23 7RG, UK.
Tel: +44 (0) 1962 828000. Fax: +44 (0) 1962 840846. Email: denplan@denplan.co.uk
Registered in England No. 1981238. Registered address 5 Old Broad Street, London, EC2N 1AD, UK.
Denplan Limited is an Appointed Representative of AXA PPP healthcare Limited which is authorised and regulated by the
                                                                                                                                                                                   CORP242 02-09




Financial Services Authority. This information can be checked by visiting the FSA register which is on their website: www.fsa.gov.uk/register
or by contacting the FSA on 0845 606 1234. Denplan Limited is regulated by the Jersey Financial Services Commission. This policy is
underwritten by AXA PPP healthcare Limited. Denplan Limited only offers dental insurance from AXA PPP healthcare Limited and is a member
of the AXA UK plc group of companies of which AXA PPP healthcare is a member. Telephone calls may be recorded for security, regulatory
and training reasons as well as monitored under our quality control procedures.

								
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