Nib Claim Form – Fill Out and Use This PDF

CLAIM FORM

Your customer number

Your family name ___________________________________ Your first name _____________________________

Your current postal address (this is the address nib will send any correspondence to do with this claim)

________________________________________________________________________________________________

____________________________________________ Daytime phone number (____________________________)

I am claiming everyday Extras (e.g. dental, optical, physio)

I am claiming medical services received in a hospital (e.g. doctors & specialists fees)

please send me a cheque made out in my name

please send me a cheque made out in my partner’s name (only available if you have authorised nib to do this)

please credit my SafeClaim account (if you have authorised nib to credit your account using a Direct Credit Authority Form)

I authorise nib to pay cash to ______________________________________________________________

If you have not yet paid the account, nib will send you a cheque to forward to your provider. You will need to pay the rest of your bill.

By signing this form, I declare that all information I have provided to nib, including all information in this form, is true & correct. I authorise nib to use this information and any other information I have previously given nib to assess and process my claim(s). I consent to nib contacting my previous health fund and/or service provider to request information and/or personal and medical records to verify any aspect of the claim(s). I acknowledge and provide consent for nib to use this information for other purposes related to this claim as outlined in the nib Privacy Policy.

I confirm these services have not been claimed as Point of Service such as iSOFT or HICAPS and that this claim is not subject to workers compensation, damages action, third party insurance or any other source.

I confirm that the services I am claiming were performed by the providers, and received by the persons as indicated on the healthcare provider’s receipts.

My claims checklist

*I have attached all the receipts and/or accounts for each item I am claiming.

*All the receipts/accounts I have attached are original, itemised in full, written in English, and are on the provider’s official stationery or have the provider’s official stamp.

*I received the services within the last two years.

(nib does not pay claims made two years or more after the services were received)

*I am claiming services from an nib recognised provider.

(nib does not pay claims for the services of providers who are not recognised by nib)

*I have claimed with Medicare for medical services I had in hospital and I have attached the top portion of the Medicare Statement of Benefits and my receipts.

*I have indicated where applicable that the claim is related to worker’s compensation.

nib health funds limited abn 83 000 124 381