Axa Ppp Healthcare Claim Form Details

The Axa Ppp International form is a document that protects your assets from being seized in the event of an accident. As more and more people are traveling internationally, this form is becoming increasingly important as it can help protect you from unforeseen losses. In order to complete the Axa Ppp International form, you will need to have completed a medical questionnaire and know which countries you plan on traveling to. The best way for those who travel frequently is to get their own copy of the Axa Ppp International Form and fill out all relevant information before they leave home so they may be protected even if something were to happen while they were outside of Canada.

You'll find it beneficial to know how much time you'll need to complete this axa ppp international form and how lengthy the document is.

QuestionAnswer
Form NameAxa Ppp International Form
Form Length4 pages
Fillable?Yes
Fillable fields68
Avg. time to fill out14 min 40 sec
Other namesppp claim form, axa reimbursement form, axa international login, axa ppp international claim form

Form Preview Example

International self-certification form

For instructions on how to claim, please read the notes below.

Complete all sections of the self-certification form. Please complete this form in block capitals. Ensure that all relevant invoices and receipts are attached. Please note that photocopies are not accepted.

Guidance notes for policyholders

Failure to answer all questions and include all required documentation will result in this self-certification form being returned to you for completion and may delay in the processing of your claim.

1.This self-certification form is not an admission of liability.

2.For audit purposes, we wil retain invoices connected with your claim. We will supply you with photocopies on request.

3.The declaration on this self-certification form must be signed and dated.

4.If you have any questions regarding this form or any other aspect of your cover, please feel free to contact us by telephone + 44 (0)1892 503 856, fax + 44 (0) 1892 503 189 or via www.axappphealthcare.co.uk/ask

5 Please send all completed/signed correspondence to AXA PPP International, International Customer Service, Phillips House, Crescent Road, Tunbridge Wells, Kent, TN1 2PL, United Kingdom.

1 Policyholder’s and patient’s details

1.1

Patient’s name:

1.4

Policyholder’s name:

 

 

 

 

 

 

 

 

1.2

Patient’s date of birth:

1.5

Customer number:

D

D

M M

Y

Y

1.3 Patient’s name and address:

1.6

Telephone number (daytime/evening):

 

 

 

 

 

 

 

 

 

 

1.7

Email address:

 

 

 

 

 

 

 

 

 

 

 

 

2Payment details

We normally settle eligible invoices direct with the hospital and medical practitioner concerned. Please check with the hospital if they will be paid directly by AXA PPP International and if so, please do not complete this section. If the invoices we receive from you have not been paid we will do that automatically. If you have already paid the invoices yourself please send us the receipts and we will reimburse you by cheque or wire transfer direct to your bank account. For reimbursements please complete this section with your bank account details. We cannot reimburse to credit or debit cards, so please do not list any card numbers on this form.

2.1

Currency for claim to be paid in:

2.4

Country:

 

 

 

 

 

 

 

 

2.2

Bank account number:

2.5

IBAN*:

 

 

 

 

 

 

 

 

2.3

Bank name and postal address:

2.6

Swift code*:

 

 

 

 

 

 

 

 

 

 

2.7

Account name:

 

 

 

 

 

 

 

 

2.8 ABA number:

*Note: the IBAN and Swift codes are required if payment is to be made in Euros

continued overleaf

AXA PPP International is a trading name of AXA PPP healthcare limited, Phillips House, Crescent Road, Tunbridge Wells, Kent, TN1 2PL, United Kingdom 1 of 4

AXA PPP healthcare limited. Registered Office: 5 Old Broad Street, London EC2N 1AD, United Kingdom. Registered in England No. 3148119. Authorised and regulated by the Financial Services Authority. In order to maintain a quality service, we may record and/or monitor calls for quality assurance, training and evidential purposes.

PB39060/07.10

3Verification of accounts

All invoices and or proof of payments made, medical certificates, correspondence or documents related to this/these claims should be attached to this self-certification form. (Where possible we will pay the in-patient bills diectly to the hospital.) Please list dates and type of treatment, invoice value and advise if you have paid any. Failure to do so may result in a delay in your claim being paid.

3.1

4Claim details

You must make sure that alll information you give us is true, accurate and complete. If we discover later it is not then we may cancel your policy or refuse your claim and we will recoup any monies we have paid in respect of that medical condition.

4.1Have you ever had or been treated for this type of injury or illness before? If yes, please give details below.

Yes

No

4.2How did the condition begin? State fully all symptoms and describe the condition in detail from the beginning. For accidents, include how, when and where the accident occurred.

4.3Please give brief details of the condition, from when you first became aware of it.

4.4If this claim is related pregnancy: is the pregancy a result of natural conception?

Yes

No

5Additional information

5.1 Hospital details

Are you claiming cash benefit

 

Yes

 

No

for in-patient treatment

 

 

 

 

 

 

 

 

 

 

received without charge?

 

 

 

 

If Yes, please state the admission and discharge dates and enclose a certificate from the hospital confirming the dates of the stay.

Admission date:

D

D

M

M

Y

Y

Discharge date:

D

D

M

M

Y

Y

5.2Third party involvement

Is the treatment because of an injury caused by an accident?

5.3If yes, did it involve a third party you may be making a claim against?

5.4Do you have any other insurance policy that could also cover your costs, for example a travel policy?

Yes

Yes

Yes

No

No

No

AXA PPP International is a trading name of AXA PPP healthcare limited, Phillips House, Crescent Road, Tunbridge Wells, Kent, TN1 2PL, United Kingdom 2 of 4

AXA PPP healthcare limited. Registered Office: 5 Old Broad Street, London EC2N 1AD, United Kingdom. Registered in England No. 3148119. Authorised and regulated by the Financial Services Authority. In order to maintain a quality service, we may record and/or monitor calls for quality assurance, training and evidential purposes.

Patient’s details

Patient’s name:

Patient’s date of birth:

D D M M Y Y

6Patient’s declaration and consent

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

I consent to AXA PPP International limited reviewing the information on this form.

I consent to AXA PPP International limited requesting medical information, if needed from the patient’s medical practitioner and/or hospital.

I consent to the medical practitioner and/or hospital providing medical reports and access to copies of such health records as may be requested by AXA PPP International limited. This is so that AXA PPP International limited can:

a.deal with the application/claim for benefit;

b.undertake audits and other investigations; and

AXA PPP International Self-certification form

Policyholder’s name:

Customer number:

6.1I declare that I am the patient

Yes

 

No

 

 

 

6.2Is the patient under 16 years of age?

Yes

 

No

 

 

 

6.3If yes, I declare that I am the patient’s parent/guardian

Yes

 

No

 

 

 

6.4I wish to see any report from the medical practitioner before it is sent to you.

Yes

 

No

 

 

 

6.5Signed*:

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

I consent to AXA PPP International limited reviewing the information in any medical reports or health records that may be requested.

I consent to the medical practitioner and/or hospital involved in the patient’s care reviewing medical or treatment details and discharge arrangements with AXA PPP International limited.

I agree that AXA PPP International limited will send all further correspondence about this claim to the policyholder unless I ask you not to.

(*To be signed by the patient or parent/guardian if the patient is under 16)

Date:

D D M M Y Y

6.6Patient’s full name

Checklist (Tick the appropriate boxes in this section)

1. Completed the patient’s details (section 1)

2. Completed the payment details (section 2/3)

3. Completed the claim details (section 4)

4. Completed the additional information (section 5)

5. Completed the declaration and consent (section 6.1–6.4)

6. Signed and dated the form (section 6.5–6.6)

If you have any questions about this form or any other aspect of your cover, please feel free to contact us by

Telephone: +44 1892 503 856, Fax: +44 1892 503 189 or email at www.axappphealthcare.com/ask

continued overleaf

AXA PPP International is a trading name of AXA PPP healthcare limited, Phillips House, Crescent Road, Tunbridge Wells, Kent, TN1 2PL, United Kingdom 3 of 4

AXA PPP healthcare limited. Registered Office: 5 Old Broad Street, London EC2N 1AD, United Kingdom. Registered in England No. 3148119. Authorised and regulated by the Financial Services Authority. In order to maintain a quality service, we may record and/or monitor calls for quality assurance, training and evidential purposes.

7Important information

Please read carefully.

Access to Medical Reports Act 1988:

You need to understand these rights before you agree to us requesting a report from the medical practitioner treating you.

These rights do not relate to reports from practitioners who are not responsible for treating you. Also, when we ask for information from your medical records, such as a copy of your medical notes, only the first point applies.

You can withhold your consent, but if you do so, we might not be able to process your claim.

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

You can indicate in the box in section 6 Declaration and consent 6.4 of this form if you would like to see any report from the medical practitioner before it is sent to us. You have 21 days from the date of our request to do this and it is up to you to contact the medical practitioner. If you change your mind before the report has been sent to us, 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 can contact the medical practitioner to change it. If the medical practitioner does not agree with you, they will ask you to write a statement to be attached to the report that is sent to us.

You can ask the medical practitioner to see the report at anytime within six months of the medical practitioner sending it to us.

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

Your medical practitioner does not have to show you parts of the report if they think it could cause harm to your physical or mental health.

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

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

Data Protection Act 1998:

Information about health, medical history and any treatment that you have is sensitive personal information.

We need your consent to process your sensitive personal information.

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

You can write to us to ask for a copy of any personal information contained in an independent report we have requested.

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

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

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

Auditing and the prevention and detection of crime.

We may audit the records of medical practitioners and hospitals to:

Ensure that we are being correctly billed for their services;

Prevent and detect crime, particularly fraud; or

Review the performance of specialists.

Audits may be part of a programme or in response to a specific circumstance and may involve reviewing customers’ medical records held by the person or organisation being audited.

We may need to share information that we receive with third parties. This includes medical experts, other insurers, the NHS Counter Fraud Security Management Service and the General Medical Council. We are required by law, in certain circumstances, to disclose information to law enforcement agencies about suspicions of fraudulent claims and other crimes.

This may involve adding non-medical information to a database that will be viewed by other insurers and law enforcement agencies. We are required to notify the General Medical Council or other relevant regulatory body about any issue where we have reason to believe a medical provider’s fitness to practise may be impaired.

AXA PPP International is a trading name of AXA PPP healthcare limited, Phillips House, Crescent Road, Tunbridge Wells, Kent, TN1 2PL, United Kingdom 4 of 4

AXA PPP healthcare limited. Registered Office: 5 Old Broad Street, London EC2N 1AD, United Kingdom. Registered in England No. 3148119. Authorised and regulated by the Financial Services Authority. In order to maintain a quality service, we may record and/or monitor calls for quality assurance, training and evidential purposes.

PB39060/07.10

How to Edit Axa Ppp International Form

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axa health insurance claim form fields to consider

Please type in the demanded information in the AXA PPP International is a trading, continued overleaf 1 of 4, 0 1 , and *Note: the IBAN and Swift codes space.

Completing axa health insurance claim form part 2

Outline the significant information in the All invoices and or proof of, 4 Claim details, You must make sure that alll, Yes, If yes, and For accidents field.

Finishing axa health insurance claim form step 3

You will have to indicate the rights and responsibilities of both parties in paragraph Yes, 5 Additional information, Are you claiming cash benefit for, Yes, Is the treatment because of an, If Yes, Admission date:, D D M M Y, Discharge date:, D D M M Y, insurance policy that could also, Yes, Yes, and Yes.

part 4 to completing axa health insurance claim form

End by reading the following sections and submitting the pertinent details: Patient’s name:, Patient’s date of birth:, D D M M Y, 6 Patient’s declaration and consent, I confirm I have read the, I consent to AXA PPP, the information on this form, I consent to AXA PPP, requesting medical information, I consent to the medical, hospital providing medical reports, Policyholder’s name:, Customer number:, Yes, and Yes.

Filling out axa health insurance claim form stage 5

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Step 4: Ensure you prevent potential misunderstandings by producing around 2 duplicates of your form.

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