AXA PPP healthcare dental claim form

PB40

917/07

.11

1.2 Date of birth:

D D M M Y Y

1.7 Policy enrolment date:

D D M M Y Y

1.1 Patient’s name:

1.3 Address:

Postcode:

1.8 Name of any other insurer:

1.4 Contact telephone number: 1.9 Telephone number of any other insurer:

1.5 Policyholder’s name:

1.6 Policy/membership number:

1 Policyholder’s details

If you have any questions about this form or your cover, please feel free to contact us on Telephone 0800 206 1781. We are open 8am to 8pm Mon to Fri and 9am to 5pm Saturdays and Bank Holidays.

Please note:• Your claim cannot be processed without an

itemised invoice confirming details of alltreatments being claimed for the original receiptof payment (credit card, debit card, cheque orcash) or a receipt from the dentist on officialheaded paper.

• Please make sure you sign the claim form. If youare on the Premium plan your dentist will alsoneed to sign the claim form.

• Please refer to your membership handbook,which will confirm the benefit categories andlevels under which to claim including waitingperiods.

• Incomplete claim forms will be returned.• All claims should be submitted within 30 days of

paying for your treatment.

1 of 4AXA PPP healthcare, Phillips House, Crescent Road, Tunbridge Wells, Kent TN1 2PL.AXA PPP healthcare limited. Registered Office: 5 Old Broad Street, London EC2N 1AD, United Kingdom. Registered in England No. 3148119.Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. © AXA PPP healthcare 2013. In order to maintain a quality service, we may record and/or monitor calls for quality assurance, training and evidential purposes.

Please return this form to:AXA PPP healthcare limited, Phillips House, Crescent Road,Tunbridge Wells, Kent, TN1 2PL UK.

2 Treatment details

2.1 Have you attended a dentist appointment in the12 months prior to the commencement of thispolicy?

2.2 Yes, with current dentist If Yes with current dentist please ask them tocomplete section 6.

2.3 Yes, with previous dentist No If yes with the previous dentist please completesections 3.4, 3.5 and 3.6.

2 of 4

3.2 Date of first visit to this dentist:

D D M M Y Y

3.6 Date of first visit to this dentist:

D D M M Y Y

5.1 Date of admission:

D D M M Y Y

5.2 Date of admission:

D D M M Y Y

D D M M Y Y

3.1 Name of current dentist:

3.3 Address:

Postcode:

3.7 Address:

Postcode:

3.4 Telephone number:

If yes, please give the name of your travel insurer:

5.3 Reason for the stay:

3.8 Telephone number:

3.5 Name of previous dentist:

3 Dentist’s details

4 Emergency or Accident

4.1 Was the treatment needed as a result of an emergency? Yes No

5 Hospital cash benefit (please enclose the hospital discharge summary if claiming this benefit)

4.2 Was the treatment needed as a result of an accident/injury? Yes No

If yes, did it relate to an injury or condition caused by another person who you may be claiming against? Yes No

4.4 Was the treatment overseas? Yes No

If yes, what date was your first emergency appointment?

D D M M Y YIf yes, what date did the accident/injury occur?

4.3 Please detail below your symptoms and if applicable, details of how the accident occured:

3 of 4

I confirm I have read the information in this form. I wish to make a claim and declare that all theinformation I have given you is, to the best of myknowledge, true and correct.

I consent to AXA PPP healthcare reviewing theinformation on this form.

I consent to AXA PPP healthcare requestingmedical information, if needed from the patient’smedical practitioner and/or hospital.

I consent to the medical practitioner and/orhospital providing medical reports and access tocopies of such health records as may be requestedby AXA PPP healthcare. This is so thatAXA PPP healthcare can:

a. deal with the application/claim for benefit;

b. undertake audits and other investigations; and

c. process and share medical information with third parties where there is a legal requirementto do so.

I consent to AXA PPP healthcare reviewing theinformation in any medical reports or healthrecords that may be requested.

I consent to the medical practitioner and/orhospital involved in the patient’s care reviewingmedical or treatment details and dischargearrangements with AXA PPP healthcare.

I agree that AXA PPP healthcare will send all furthercorrespondence about this claim to the policyholderunless I ask you not to.

7.6 Signatory's full name

7.1 I declare that I am the patient

Yes No

7.2 Is the patient under 16 years of age?

Yes No

7.3 If yes, I declare that I am the patient’sparent/guardian

Yes No

7.4 I wish to see any report from the medicalpractitioner before it is sent to you.

Yes No

7 Patient’s declaration (to be completed by the policyholder if patient is under 16)

7.5 Signed*:

Date:

D D M M Y Y

(*To be signed, by the patient or parent/guardianif the patient is under 16)

I confirm the above patient has been treated by me during the last 12 months prior to the above policy enrolment date (first appointment only).

I confirm the treatment detailed on the invoice provided has been undertaken and the amount of £____________ has been paid.

6 Dentist’s declaration (to be completed by your dentist)

Dentist’ssignature:

D D M M Y Y

Printname:

PracticeStampHere

Date: GDCNumber:

Access to Medical Reports Act 1988:You need to understand these rights before you agree tous requesting a report from the medical practitionertreating you. These rights do not relate to reports from practitionerswho are not responsible for treating you. Also, when weask for information from your medical records, such as acopy of your medical notes, only the first point applies.

You can withhold your consent, but if you do so, we mightnot be able to process your claim.

If we need a report we will write to you to tell you the dateit was requested.

You can indicate in the box in section 7 Declaration andconsent 7.4 of this form if you would like to see anyreport from the medical practitioner before it is sent to us.You have 21 days from the date of our request to do thisand it is up to you to contact the medical practitioner. Ifyou change your mind before the report has been sent tous, you can contact your medical practitioner to see it.You have 21 days from the date of our request to do this.

If you disagree with the information in the report, you cancontact the medical practitioner to change it. If themedical practitioner does not agree with you, they will askyou to write a statement to be attached to the report thatis sent to us.

You can ask the medical practitioner to see the report atany time within six months of the medical practitionersending it to us.

Your medical practitioner may charge you for a copy of thereport. This charge is not covered by your scheme/policy.

Your medical practitioner does not have to show you partsof the report if they think it could cause harm to yourphysical or mental health.

If the report includes information about someone else, the medical practitioner will not show you that part of thereport.

If the medical practitioner does not want you to see partof their report, they will tell you in writing, but you can stillview other parts of the report.

Data Protection Act 1998:Information about health, medical history and anytreatment that you have is sensitive personalinformation.

We need your consent to process your sensitive personalinformation.

You are entitled to receive information we hold aboutyou. We may make a small charge for providing this.

You can write to us to ask for a copy of any personalinformation contained in an independent report we haverequested.

If you would like a copy of a medical report that yourmedical practitioner has sent to us, you will need tocontact them directly.

Your claims may be processed in confidence on ourbehalf, outside the European Economic Area.

We will send all claims correspondence to thepolicyholder unless you ask us not to.

Auditing and the prevention and detection of crime.We may audit the records of medical practitioners andhospitals to:

Ensure that we are being correctly billed for theirservices;

Prevent and detect crime, particularly fraud; or

Review the performance of specialists.Audits may be part of a programme or in response to aspecific circumstance and may involve reviewing customers’medical records held by the person or organisation beingaudited.

We may need to share information that we receive with thirdparties. This includes medical experts, other insurers, theNHS Counter Fraud Security Management Service and theGeneral Dental Council. We are required by law, in certaincircumstances, to disclose information to law enforcementagencies about suspicions of fraudulent claims and othercrimes.

This may involve adding non-medical information to adatabase that will be viewed by other insurers and lawenforcement agencies. We are required to notify the GeneralMedical Council or other relevant regulatory body about anyissue where we have reason to believe a medical provider’sfitness to practise may be impaired.

8 Important information

PB40

917/07

.11

4 of 4AXA PPP healthcare, Phillips House, Crescent Road, Tunbridge Wells, Kent TN1 2PL.AXA PPP healthcare limited. Registered Office: 5 Old Broad Street, London EC2N 1AD, United Kingdom. Registered in England No. 3148119.Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. © AXA PPP healthcare 2013. In order to maintain a quality service, we may record and/or monitor calls for quality assurance, training and evidential purposes.