CLAIM FORM Private Health Insurer · J O H N (dd/mm/yy) Queensland Country Health Fund Ltd ABN 18...
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J O H N Queensland Country Health Fund Ltd ABN 18 085 048 237 is a Registered Private Health Insurer PLEASE USE A BLACK PEN AND PRINT IN CAPITAL LETTERS INSIDE THE BOXES. 1. YOUR DETAILS 2. CLAIM DETAILS 3. PAYMENT METHOD ACKNOWLEDGEMENT AND DECLARATION Member Number Please include itemised receipts/accounts with your claim form. Receipts and other supporting documentation will be retained by Queensland Country Health Fund. Please keep a copy of these documents for your records. PLEASE NOTE: All unpaid accounts will be processed and paid directly to the provider Mark with a I declare that: Member Signature Date (dd/mm/yy) 1. All the information on this form is true and correct. 2. I authorise Queensland Country Health Fund to use my personal information and to disclose this information to other parties including medical practitioners, health service providers and hospitals as reasonably necessary in assessing and processing this claim and for other purposes as provided in the Queensland Country Health Fund Privacy Policy. I confirm that all persons recorded on this form have also provided their consent to such use and disclosure of their personal information. 3. Unless otherwise provided to Queensland Country Health Fund in writing, the services listed on this claim cannot be claimed from other sources including Medicare Australia, workers compensation, motor vehicle accident insurance or third party liability. Where payment of these services is received from another source, I agree to reimburse Queensland Country Health Fund for the amount paid in benefits under this claim. 4. I am aware of the rules relating to claiming benefits as set out in the Health Fund Membership Guide. PRIVACY POLICY Queensland Country Health Fund collects personal information for a number of purposes and is committed to protecting your personal information and complying with the requirements of the Privacy Act. Personal information requested on this claim form is collected for the primary purpose of processing health benefit claims in respect of Members (including dependants) covered under the private health insurance policy. For more information about the Queensland Country Health Fund Privacy Policy please refer to qldcountryhealth.com.au or call 1800 813 415. I would like my benefits to be paid into my previously nominated financial institution account. I would like my benefits to be paid into a new financial institution account (if yes, please complete section 4 on next page). Patient First Name Provider Number Item # Paid $ $ $ $ $ $ $ $ $ $ 1 2 3 4 5 6 7 8 9 10 . . . . . . . . . . Tooth # Service ID Cost of Service ($) Patient DOB (dd/mm/yy) Service Date (dd/mm/yy) Dental Claims First Name Surname Service ID Key (see below) Processor Claim Number MAS – Massage CHI – Chiropractor POD – Podiatry NAT – Naturopath DEN – Dental PHR – Pharmacy PHY – Physiotherapy ACT – Acupuncture OST – Osteopathy OPT – Optical If your service is not listed above please leave blank CLAIM FORM EXAMPLE:
Transcript of CLAIM FORM Private Health Insurer · J O H N (dd/mm/yy) Queensland Country Health Fund Ltd ABN 18...
J O H N
Queensland Country Health Fund Ltd ABN 18 085 048 237 is a Registered Private Health Insurer
PLEASE USE A BLACK PEN AND PRINT IN CAPITAL LETTERS INSIDE THE BOXES.
1. YOUR DETAILS
2. CLAIM DETAILS
3. PAYMENT METHOD
ACKNOWLEDGEMENT AND DECLARATION
Member Number
Please include itemised receipts/accounts with your claim form. Receipts and other supporting documentation will be retained by Queensland Country Health Fund. Please keep a copy of these documents for your records.
PLEASE NOTE: All unpaid accounts will be processed and paid directly to the provider
Mark with a
I declare that:
Member Signature
Date (dd/mm/yy)
1. All the information on this form is true and correct.2. I authorise Queensland Country Health Fund to use my personal information and to disclose thisinformation to other parties including medical practitioners, health service providers and hospitals asreasonably necessary in assessing and processing this claim and for other purposes as provided in theQueensland Country Health Fund Privacy Policy. I confirm that all persons recorded on this form havealso provided their consent to such use and disclosure of their personal information.3. Unless otherwise provided to Queensland Country Health Fund in writing, the services listed on thisclaim cannot be claimed from other sources including Medicare Australia, workers compensation, motorvehicle accident insurance or third party liability. Where payment of these services is received fromanother source, I agree to reimburse Queensland Country Health Fund for the amount paid in benefitsunder this claim.4. I am aware of the rules relating to claiming benefits as set out in the Health Fund Membership Guide.
PRIVACY POLICYQueensland Country Health Fund collects personal information for a number of purposes and is committed to protecting your personal information and complying with the requirements of the Privacy Act. Personal information requested on this claim form is collected for the primary purpose of processing health benefit claims in respect of Members (including dependants) covered under the private health insurance policy. For more information about the Queensland Country Health Fund Privacy Policy please refer to qldcountryhealth.com.au or call 1800 813 415.
I would like my benefits to be paid into my previously nominated financial institution account.
I would like my benefits to be paid into a new financial institution account (if yes, please complete section 4 on next page).
Patient First Name Provider Number Item # Paid
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Tooth # Service ID Cost of Service ($)Patient DOB(dd/mm/yy)
Service Date(dd/mm/yy)
Dental Claims
First Name Surname
Service ID Key (see below)
Processor
Claim Number
MAS – MassageCHI – ChiropractorPOD – PodiatryNAT – NaturopathDEN – Dental
PHR – PharmacyPHY – PhysiotherapyACT – AcupunctureOST – OsteopathyOPT – Optical
If your service is not listed above please leave blank
CLAIM FORM
EXAMPLE:
Please tick this box if you would like these account details to be saved for all future claims.
Financial Institution Name Account Name
(only complete if your address has changed)
Please tick this box if you would like this address recorded permanently on your membership
Street Address
There are a number of ways you can claim for your extras services: On-the-spot (at your provider’s placeof business) by swiping your Membership Card; on your mobile by downloading our app for iPhone orAndriod; online claiming through Online Member Services; email or post -
Mobile App: Download from the App Store for iPhones or Google Play for Android Online: qldcountryhealth.com.au Email: [email protected] Post: PO Box 42 Aitkenvale QLD 4814
We can deposit your benefits straight into your financial institution account. We will endeavour to have your claim processed within 3-5 business days of receipt of the claim.
Suburb State Postcode
Suburb
Postal Address
Home Phone Number-
Mobile Number
Email Address
State Postcode
BSB Number Account Number
4. DIRECT CREDIT DETAILS
6. CLAIM YOUR WAY
5. CHANGE OF CONTACT DETAILS
QCH 0030 V9 05/17
7. INSTRUCTIONSOriginal receipts/accounts must accompany all claim forms. They should be fully itemised including the patient’s name, and the name, address and details of the provider. Benefits areonly paid on claims that are less than two years old (24 months).
8. ONLINE MEMBER SERVICESBy using the website qldcountryhealth.com.au you can access all of your membership details and benefit availability 24/7. The ‘Login’ icon is located in the top right hand corner of the screen. Once you have registered using your membership number and your choice of password, click on the login tab and enter your membership number and password. Now you’re ready to go!
Below are some of the things you can do by using Online Member Services:
• View claims history• View/Print tax statement• Change personal details• Update Membership details
• Add a new person• View benefit limits• Add student dependant• Change contact details
• Update your method of payment
• Change direct credit details for claim benefits
9. RECOVERY OF BENEFITSQueensland Country Health Fund has the right to recover benefits paid for services whichthe Member is not entitled to claim for, as per our Fund Rules. These costs can berecovered from contributions paid in advance.
10. COMPENSATIONIf a Member has an accident or is injured (e.g. in a motor vehicle accident, or as a result oftheir employment) they may be ineligible for any benefits from Queensland CountryHealth Fund for any treatment relating to that accident or injury. If a Member has receivedor might have the right to receive compensation or damages from a third party, thesemedical costs are not payable by Queensland Country Health Fund. This is irrespective ofwhether the Member pursues a claim or not. If such costs are initially paid by QueenslandCountry Health Fund, the liability of the Member to repay shall apply regardless ofwhether the Member continues to be a Member of Queensland Country Health Fund.
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qldcountryhealth.com.au | Email [email protected] | Call 1800 813 415PO Box 42 Aitkenvale QLD 4814
Queensland Country Health Fund Ltd ABN 18 085 048 237
