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AXA PPP healthcare MultiCare International Health Plan Claim Form • You must fully complete sections 1, 2, 3 and 4. • Your medical practitioner must fully complete sections 5, 6, and 7 in full. • Both you and your medical practitioner must sign and date this form and it must be accompanied by original receipted and numbered invoices, prescriptions and diagnostic test results or it may not be processed. • You must provide your passport/ID number in order for us to process your claim. 1. Member’s and Patient’s details Member’s name and Passport/ID number Patient’s name and Passport/ID number Patient’s address Tel no: Mob no: Fax no: Email: Membership number from your card Group number (if applicable) Member’s date of birth Patient’s date of birth (if different) Daytime phone number Patient’s relationship to member 2. To be completed by Patient (or member if Patient is under 18 years of age) 1. If payment is to be made to someone other than the subscriber (eg. the Patient’s guardian) please complete the following: I authorise benefit to be paid directly to Address Signature of subscriber Date 3. If treatment was received outside Cyprus, you must answer the following questions: (a) Country where treatment took place (b) The reason for the patient being abroad 4. Are you claiming cash benefit for in-patient treatment? Please tick ✓ Yes No If yes, please enclose a copy of your admission and discharge forms from the hospital. In which currency was the treatment originally billed? Name and telephone number of patient’s family doctor Account no Sort code Name of account holder Bank (c) Dates of departure and return to own area of cover from to 3. Other insurer’s details Is the treatment accident-related? Please tick ✓ Yes No Is it covered under another insurance policy? Yes No Stamps If you have any questions regarding this form or any other aspects of your cover, please telephone on: +357 22 88 22 22 – ask for the Accident & Health Department. 2. Payments will be made in Euros unless we agree otherwise in writing. If you have answered ‘Yes’ to either of these questions, please give the name of the insurance company involved.
