Indicate type of condition: Acute Chronic Acute episode of chronic
Please provide full details of the symptoms/medical condition requiring treatment, including ICD9/10 code/DSM-IV
ICD9/10 code DSM-IV
On what date did the patient first present these symptoms to you?
On what date would the first onset of symptoms have been apparent to the patient?
Has the patient suffered from this condition previously? Yes
No If Yes, when?
Are you aware of any treatment given for this or any related illness in the past? Yes No
If Yes, please provide details
Is it likely to re-occur? Yes No
Does it need rehabilitation? Yes No
Is it permanent? Yes No
Does it need long term monitoring, consultations, check ups, examinations or tests? Yes No
Please provide the Guarantee of Payment (GOP) reference number that relates to this treatment (where available):
Applicable to cases of pregnancy only:
Estimated date of delivery
Is birth of a single baby expected? Yes No
If you answered No to the question above and twins/multiple babies are expected, is the pregnancy a result of medically assisted reproduction other than artificial
insemination?
Yes No
If Yes, please provide further details
Applicable to physiotherapy/psychotherapy claims only. Please provide full referral details:
Name of referring physician
Telephone
Date of referral
Please sign, date and authenticate with an official stamp.
Doctor’s signature
Date
Official stamp of medical provider
Policy Number
First name
Surname
Date of birth
Correspondence address
Telephone
Email
1 PATIENTDETAILS
2 MEDICALDETAILS
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
COUNTRY
CODE
COUNTRY
CODE
AREA
CODE
AREA
CODE
MEDICALPROVIDER
CLAIMFORM
For your convenience, this form (editable PDF version) is available on our website: www.allianzworldwidecare.com/medical-
provider-claimform. If you choose to complete this form in handwriting please use BLOCK CAPITALS.
Please send the fully completed Medical Provider Claim Form(s) with original invoices attached (photocopies
cannot be accepted) to the following address:
Claims Department, Allianz Partners, 15 Joyce Way, Park West Business Campus, Nangor Road,
Dublin 12, Ireland.
We advise that you keep copies of all correspondence with us as we cannot be held responsible for correspondence that does not reach us for any reason that is
outside of our reasonable control.
If you have any queries please contact our Helpline on: + 353 1 630 1301 or email: [email protected]
For our latest list of toll-free numbers, please visit: www.allianzworldwidecare.com/toll-free-numbers
FRM-PCF-EN-1117
Our Data Protection Notice explains how we protect your privacy. This is an important notice which outlines how we will process your personal data and should be
read by you before the submission of any personal data to us. To read our Data Protection Notice visit: www.allianzworldwidecare.com/en/privacy
Alternatively, you can contact us on + 353 1 630 1301 to request a paper copy of our full Data Protection Notice. If you have any queries about how we use your
personal data, you can always contact us by email at: [email protected]
I certify that to the best of my knowledge, this Claim Form does not contain any false, misleading or incomplete information. I understand that in the event that
this claim is found to be fraudulent, in whole or in part, the contract may be cancelled from the date of discovery of the fraudulent event and I may be liable to
prosecution.
I agree to waive any rights that I may have to medical secrecy/confidentiality in respect of my medical information and I authorise my medical practitioner, health
professional or other relevant medical establishment to provide relevant medical information relating to me, if requested by Allianz Partners, its medical advisers, its
appointed representatives, or to any third party expert(s) in case of disputes, subject to any legal restrictions which may apply.
Important – please check the following:
All original receipts, invoices and prescriptions are attached.
The Medical Provider Claim Form is completed in full (including GOP
reference number, where available).
The declarations are signed and dated.
The diagnosis has been confirmed and is either stated on the Medical
Provider Claim Form or on the invoices.
3 WECAREABOUTYOURPERSONALDATAPROTECTION
4 DECLARATION
If a minor was treated, a parent or guardian should sign and date this section.
Patient’s signature
Date
AWP Health & Life SA, acting through its Irish Branch, is a limited company governed by the French Insurance Code. Registered in France: No. 401 154 679 RCS Bobigny. Irish Branch registered in
the Irish Companies Registration Office, registered No.: 907619, address: 15 Joyce Way, Park West Business Campus, Nangor Road, Dublin 12, Ireland. Allianz Partners is a registered business name
of AWP Health & Life SA.
DD/MM/YYYY
TOBESIGNEDANDDATEDBYTHEPATIENT
✔
✔