Medical information form at a glance
What it is: The Medical information form has three parts: A: Claim Details, B: Patient Consent and C: Medical Details, completed by the patient or the patient's Doctor or Medical Practitioner.
Who signs: The patient signs Part B by hand. AXA does not accept electronic signatures. Signed is marked *: if the patient is under 16, this form must be signed by their parent/legal guardian. The medical practitioner signs the C2 Medical practitioner declaration.
A filled-in Medical information form example: a patient fills out Part A
How to fill out Medical information form, box by box
About you and your claim
Use BLACK INK and write in BLOCK CAPITALS throughout.
Enter the Full name and title, then the Address with full address details, including postal code and country where applicable.
Under Contact details, include country and area codes, where applicable, in the Telephone and Email lines. Give the Parent or Legal Guardian's details if the patient is under 16.
Enter the Date of birth.
Under Reason for claim, describe the symptoms or medical condition being treated.
Enter the Membership/customer number and the Claim number (if known).
A2 Claim payment details
Have you already paid any bills for the treatment you're claiming for? If no, go to section A3. If yes, complete the rest of this section.
Attach all itemised receipted invoices for the treatment as well as any medical certificates, correspondence or documents relevant to the claim.
To avoid any delays with your claim, list: The dates of the treatment, The type of treatment, The medical condition, The invoice value.
Enter the Currency for claim to be paid in, the Country and the Bank account number.
Enter the IBAN (if relevant to your bank's location), the SWIFT or BIC code and the ABA number (if relevant to your bank's location).
Enter the Payee name, the Account name, and the Bank name and address.
A3 Further information
Do you want to claim a cash benefit for treatment received free of charge? If yes, send confirmation of the dates of your stay or treatment with this form and proof that the services were provided free of charge.
Do you have another insurance policy that would also cover your claim? No or Yes. If yes, give details under Other insurer details.
Is the treatment following an injury or accident? If no, go to Part B. If yes: a. Do you feel that someone else was at fault and caused the accident or injury?
Part B: Declaration and Consent
"I declare that all the information I have given on this form is correct to the best of my knowledge."
Please tick yes or no for each reason the form lists: to assess and subsequently review my claim and apply policy terms/exclusions (if you tick no AXA may not be able to process your claim).
Is the patient under 16 years of age? No or Yes. If the patient is under 16, this form must be signed by their parent/legal guardian.
Enter the Date and the Patient's full name.
I wish to see any report from the medical practitioner before it is sent to you: No Yes.
I wish for another person/other organisation(s) to help me with this claim: No or Yes. By answering yes you agree that AXA or any policy administrator and the person/organisation(s) named may discuss this claim and to the extent necessary disclose to each other your relevant health and medical details. If you answered yes please give the name of the person or organisation(s) here.
Medical information from the medical practitioner
Part C: Medical information is to be completed by the patient's medical practitioner - please help AXA by typing or writing clearly.
Do you have access to the patient's medical history? If no, please tell AXA the name and address of the person who holds the patient's medical history file.
Was the patient referred to you by another medical practitioner? No or Yes. If yes, please provide name and contact details of referring medical practitioner.
Is the claim related to or as a result of any previous surgery or treatment? No or Yes. If yes, please detail, including dates.
Does the patient have any associated or related medical conditions? No or Yes. If yes, please state and explain the relation and date of diagnosis.
Is the patient taking any medication for this condition? No or Yes. If yes, name of drug and date of starting medication.
C2 Medical practitioner declaration
I am the patient's medical practitioner and confirm that the information I have provided is correct to the best of my knowledge. I understand that, if any of the information is incorrect, this may affect my patient's claim for private healthcare expenses
Under C2 Medical practitioner declaration, sign at Signature, then enter the Contact telephone number, Practice Stamp, Print name, Date and Email address.
More rules for Medical information form
If AXA requests a medical report with details of your current condition, the history of your condition and any proposed treatment you don't have to give your consent however if you don't give consent AXA may not be able to process your claim.
Common questions about Medical information form
Is there a deadline?
If you wish to see the report before it is sent to AXA, please tick the box under Medical Reports. AXA will write to you to tell you the date it requests the report and you must contact the medical practitioner within 21 days of the date of its request. You have 21 days from the date of contacting your medical practitioner to arrange to see it.
Where do I file it?
Send the completed form by upload or secure email via axaglobalhealthcare.com/customer, by Fax: +44 (0) 1892 508256, or by Post: AXA - Global Healthcare, Phillips House, Crescent Road, Tunbridge Wells, Kent, TN1 2PL, UK.
Sources
[1] Medical information form (PB63233/01.21), AXA (the Official source link on this page).
