Form Allianz – Fill Out and Use This PDF

The Allianz form serves as a critical tool for individuals seeking reimbursement or direct billing for medical expenses incurred under International Healthcare Plans for Qatar. Detailed instructions and the requirement for completing the form in BLOCK CAPITALS facilitate a streamlined claims process, with the option for policyholders to submit their claims through a convenient PDF format available on the Allianz website or through the MyHealth app for swift submission. For simplified claim handling, ensure to click the button below to fill out your Allianz form accurately.

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Form Allianz PDF Details

Ensuring you have the right international healthcare plan in place is crucial, especially when residing or traveling abroad. The Allianz International Healthcare Plan for Qatar comes with a specific claim form that policyholders must complete thoroughly to facilitate the processing of their medical claims. This comprehensive form, available in a PDF format for convenience on the Allianz website, simplifies the claims process considerably. By allowing for quick and easy claims submission through the MyHealth app, where users can simply provide a few key details and take a photo of their receipt(s), the hassle typically associated with claim filing is significantly reduced. The form requests detailed information, including policyholder and patient details, choice of payment method to either the policyholder or directly to the medical provider, along with banking information for reimbursements. An essential part of this process involves accurately detailing each medical expense incurred, alongside the diagnosis or medical condition that necessitated such expenses. Moreover, it covers sections dedicated to the treating doctor's details, medical particulars of the condition treated, and even includes stipulations for data protection and consent regarding the use and disclosure of medical information. This systematic approach ensures that all facets of the medical claim are clearly communicated, potentially expediting the claims processing time while assisting policyholders in managing their international healthcare needs efficiently.

Question	Answer
Form Name	Form Allianz
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	allianz change of agent form, blank templates, allianz annuity forms, allianz forms download

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International Healthcare Plans for Qatar

Claim Form

Please complete this form in BLOCK CAPITALS. For your convenience, this form (in PDF format) is available on our website: www.allianzworldwidecare.com/cfq

Download our

MyHealth app

Quick and easy claims submission

1.Provide a few key details

2.Take a photo of your receipt(s) And you’re done www.allianzworldwidecare.com/myhealth

1 Policyholder’s details

Policy Number

First name

Surname

Date of birth (DD/MM/YY)

Latest correspondence address

Telephone number (incl. country code and area code)

2 Patient’s details (if different from policyholder)

First name

Surname

Date of birth (DD/MM/YY)								Gender:	Male	Female

3 Payment details

Option 1: Payment to policyholder

Preferred payment method: Bank transfer* Cheque**

Please specify the currency you would like to be reimbursed in (and ensure that your bank account supports it)

Name of bank account holder as shown on your bank statement

Account number

IBAN (where required)***

Sort/branch codeBIC/Swift code***

Name of bank

Bank address

If you are aware of any additional information required in order to process international transactions within your country (e.g. Agency Code, Tax ID), please list below:

Swift code of intermediary bank (where applicable)

*For bank transfer, please provide bank details.

**Cheques payable to the policyholder will be sent to the correspondence address provided in section 1.

***If your bank is within the EU, or if your specific country requires an IBAN (e.g. Qatar, Saudi Arabia, Angola, Tunisia, Turkey), please supply both your IBAN and BIC/Swift code to facilitate the payment of your claim.

Option 2: Payment to medical provider (e.g. hospital, specialist)****

Please tick if direct billing has been previously agreed with us

**** If you have not already paid the medical provider.

4 Claim details

Please complete all parts of the following table with the details of each invoice/receipt, making sure to include the amount charged. If your invoice/receipt does not include the diagnosis/medical condition, please ensure that you provide us with this information below. If there is not sufficient space in the table below, please provide details on a separate page.

Description of expense/treatment

Diagnosis/medical condition

Provider’s name

Amount charged/

currency

Has this bill been

paid by you?

Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No
Yes	No

In what country did the treatment take place?

Has pre-authorization been obtained?

Yes

If this claim is resulting from an accident or work-related illness/injury and you hold any other insurance policy (e.g. car insurance), or if you are filing a claim or lawsuit against a third party to recover the costs incurred as a result of this accident/injury, please provide details in a separate document.

(incl. country code and area code)

Sections 5 and 6 are to be completed by the treating doctor unless detailed in the supporting documentation (e.g. receipts or invoices).

5 Medical provider’s details

Name of doctor/specialist

Qualifications/credentials

Name of hospital/clinic

Address

Telephone number (incl. country code and area code)

Fax number (incl. country code and area code)

Applicable to physiotherapy/psychotherapy claims only. Please provide full referral details:

Name of referring physician

Telephone number

Date of referral (DD/MM/YY)

6 Medical details

Indicate type of treatment received	Elective	Emergency
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

On what date did the patient first present these symptoms to you? (DD/MM/YY)

On what date would the first onset of symptoms have been apparent to the patient? (DD/MM/YY)

Has the patient suffered from this condition previously?	Yes	No	If Yes, when? (DD/MM/YY)
Has the patient suffered from this condition previously?	Yes	No	If Yes, when? (DD/MM/YY)
Are you aware of any treatment given for this or any related illness in the past?			Yes	No
If Yes, please provide details
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

Applicable to cases of pregnancy only:
Estimated date of delivery (DD/MM/YY)	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

If Yes, please provide further details

Applicable to dental treatment claims only:

Was the patient suffering from dental pain at the time he/she visited you for treatment? Yes

Please sign and authenticate with an official stamp.

Official stamp of medical provider

Doctor’s signature

Date (DD/MM/YY)

INSERT NAME OF THIRD PARTY

7Data Protection and release of medical records

References to information includes personal information given by you to us, in your Application, Claim or Pre-authorization Form and/or supporting documents/information we collect in connection with products or services we provide. Allianz Worldwide Care, part of the Allianz Group, is the data controller for this information.

Uses: Personal information may be used for insurance administration (e.g. underwriting, claims handling, fraud prevention). We may use third parties to process data on our behalf. Such processing is subject to contractual restrictions regarding confidentiality and security in line with Data Protection obligations.

Sensitive data: We need to collect sensitive data relating to you (e.g. health details), to assess insurance terms and/or administer claims.

Disclosure: We may share your information with our agents, members of the Allianz Group, other insurers and their agents, service providers, any intermediary acting on your behalf or governing/regulatory bodies (of which we are a member or by which we are governed). In certain circumstances, we may use private investigators to investigate a claim you have submitted.

Retention: We are obliged to retain your records for six years from the date the insurance relationship ends. We will not retain your data for longer than necessary and will hold it only for the purposes for which it was obtained.

Representation and Consent: By signing this form you confirm that you have the authority to act on behalf of your dependants in respect of all personal information you provide to us, and that you consent to the disclosure, processing, usage and retention of this information in relation to yourself and on behalf of your dependants.

Access: You have the right to request and receive a copy of your personal data held by us. If you wish to do this, please write to the Data Protection Officer at the address provided on this form or via client.services@allianzworldwidecare.com.

Call recording: Calls to our Helpline will be recorded and may be monitored for training, quality and regulatory purposes.

Direct marketing: Personal data collected by us will not be used to contact you for direct marketing purposes, unless you have consented to this.

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 will 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 Worldwide Care, 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.

If a minor was treated, a parent or guardian should sign this section.

Patient’s signature

Date (DD/MM/YY)

8Third party authorisation

As the claimant, I hereby authorise

to act for and on my behalf in relation to the administration of this claim, which may include the disclosure of sensitive medical information.

Claimant’s signature

Claimant’s printed name

Date (DD/MM/YY)

Please send your fully completed Claim Form(s) with invoices/receipts as follows:

Scan and email to:	claims@allianzworldwidecare.com
Fax to:	+ 353 1 645 4033
Post to:	Claims Department, Allianz Worldwide Care, 15 Joyce Way, Park West Business Campus, Nangor Road,
	Dublin 12, Ireland.

It is your responsibility to retain any original supporting documentation (e.g. medical receipts) where copies are submitted to us, as we reserve the right to request original supporting documentation/receipts up to 12 months after claims settlement for fraud detection purposes. In addition, 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.

Please contact our Helpline if you have any queries: +353 1 517 6988 or email: client.services@allianzworldwidecare.com.

For our latest list of toll-free numbers, please visit: www.allianzworldwidecare.com/toll-free-numbers

Important - please check the following:
	All receipts, invoices and prescriptions are included.	The diagnosis has been confirmed and is either stated on the Claim Form or on the


	The Claim Form is completed in full.	invoice(s).


	The declarations are signed and dated.	If you have changed your contact details, please let us know on the Claim Form.

Allianz Worldwide Care SA. QFC Branch address: Office 604-C, 6th floor, Jaidah Square Building, 63 Airport Road, Zone 27, Umm Ghuwailina, P.O. Box 31316, Doha, Qatar.

Phone: +974 4433 7455. Fax: +974 4410 1500. Website: www.allianzworldwidecare.com

Authorised by the Qatar Financial Centre Regulatory Authority. Allianz Worldwide Care SA is incorporated in France.

FRM-CF-Qatar-EN-0914

How to Edit Form Allianz Online for Free

You can certainly get forms taking advantage of our PDF editor. Revising the allianz forms form is effortless in case you use the next actions:

Step 1: Select the button "Get Form Here" on the webpage and select it.

Step 2: At this point, you're on the form editing page. You may add information, edit existing details, highlight certain words or phrases, put crosses or checks, insert images, sign the form, erase needless fields, etc.

These particular segments will compose the PDF form that you will be filling in:

stage 1 to filling in allianz life insurance company of north america forms

You should note your data within the field Option Payment to policyholder, Preferred payment method, Bank transfer, Cheque, Please specify the currency you, Name of bank account holder as, Account number, IBAN where required, Sortbranch code, Name of bank, Bank address, BICSwift code, If you are aware of any additional, Swift code of intermediary bank, and For bank transfer please provide.

stage 2 to completing allianz life insurance company of north america forms

The system will require for more info to quickly fill in the part Claim details, Please complete all parts of the, Description of expensetreatment, Diagnosismedical condition, Providers name, Amount charged currency, Has this bill been paid by you, Yes, Yes, Yes, Yes, Yes, Yes, Yes, and Yes.

Entering details in allianz life insurance company of north america forms stage 3

The Yes, Yes, Yes, Yes, Yes, Yes, Yes, Yes, Yes, Yes, Yes, and Yes box will be your place to put the rights and responsibilities of all sides.

stage 4 to finishing allianz life insurance company of north america forms

End by taking a look at the following sections and filling them in as needed: Yes, In what country did the treatment, Has preauthorization been obtained, Yes, cid, and If this claim is resulting from an.

part 5 to finishing allianz life insurance company of north america forms

Step 3: When you are done, hit the "Done" button to export the PDF document.

Step 4: Make a minimum of a couple of copies of your document to avoid any specific upcoming problems.

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