Health Shield - Hospital Based Benefit Claim Form

	FOR OFFICE USE ONLY
PLEASE REFER TO YOUR MEMBERSHIP PLAN WHEN CLAIMING BENEFITS. PLEASE MAKE SURE YOU COMPLETE YOUR MEMBER NUMBER AS YOUR CLAIM COULD BE DELAYED.

1 MEMBER'S PERSONAL INFORMATION
TITLE	SURNAME	FORENAME(S)

DATE OF BIRTH (DD/MM/YY)

MEMBER NUMBER

FULL POSTAL ADDRESS (INCLUDE POST CODE)

CONTACT EMAIL ADDRESS

CONTACT TELEPHONE NUMBER

EMPLOYMENT COMPANY DETAILS (IF APPLICABLE)

PAY OR EMPLOYEE NUMBER (IF APPLICABLE)

2 METHOD OF BENEFIT PAYMENT

HOW DO YOU WISH THIS PAYMENT TO BE MADE?

CHEQUE SEE(A)

EXPRESS DIRECT CREDIT SEE(B)

(A) CHEQUES TO BE MADE PAYABLE TO
(IF DIFFERENT FROM THE MEMBER)

PLEASE TICK IF YOU DON'T WISH YOUR DIRECT CREDIT NOTIFICATION TO BE SENT BY EMAIL

TITLE

SURNAME

FORENAME(S)

(B) COMPLETE THIS SECTION TO BE PAID BY DIRECT CREDIT (IF YOU HAVE ALREADY PROVIDED THESE DETAILS THEN THERE IS NO NEED TO FILL THEM IN AGAIN UNLESS YOUR ACCOUNT DETAILS HAVE ALTERED)

BANK/BUILDING SOCIETY NAME	ACCOUNT NUMBER	SORT CODE
		--

3 HOSPITAL CLAIMS

THE MEMBER MUST FILL IN SECTION 3. THIS MUST THEN BE CHECKED, SIGNED AND STAMPED AT THE HOSPITAL, REGISTERED TREATMENT CENTRE OR HOSPICE. ALTERNATIVELY, PLEASE ENCLOSE PROOF OF YOUR HOSPITAL STAY BY SENDING YOUR INPATIENT LETTER. PLEASE ALLOW 2 TO 3 WEEKS WHEN CLAIMING THESE BENEFITS.

TITLE	PATIENT´S SURNAME	PATIENT´S FORENAME(S)
NAME OF HOSPITAL

Tick as applicable
WAS ADMITTED AS AN INPATIENT	WAS ADMITTED AS A DAY-SURGERY PATIENT	PARENT ACCOMPANYING CHILD OVERNIGHT
	AND WAS GIVEN ANAESTHETIC/SEDATION? YES NO	NAME OF PARENT

ADMISSIONS	DATE ADMITTED	DATE DISCHARGED	NUMBER OF DAY CASE /OVERNIGHT STAYS
1ST ADMISSION	(DD/MM/YY)	(DD/MM/YY)
2ND ADMISSION	(DD/MM/YY)	(DD/MM/YY)

HAS THE PATIENT BEEN ON HOME LEAVE? YES NO
IF 'YES', STATE DATES

HAS THE PATIENT PREVIOUSLY BEEN ADMITTED FOR THIS CONDITION? YES NO

I CERTIFY THAT THE PATIENT WAS ADMITTED ON THESE DATES FOR THE FOLLOWING MEDICAL CONDITION(S)
DETAILED BELOW

OFFICIAL STAMP OF HOSPITAL,
REGISTERED TREATMENT CENTRE OR HOSPICE POSITION OF AUTHORISED OFFICIAL


	SIGNATURE OF AUTHORISED OFFICIAL
	DATE (DD/MM/YY)

4 FOR MATERNITY - ANTENATAL APPOINTMENT AND ADOPTION CLAIMS ONLY
THIS SECTION MUST BE COMPLETED BY THE G.P. SURGERY OR HOSPITAL IF CLAIMING MATERNITY – ANTENATAL. IF MAKING A CLAIM FOR ADOPTION OF A CHILD AGED THREE OR YOUNGER PLEASE ATTACH A COPY OF THE ADOPTION PAPERS.
DATE OF SCAN	OFFICIAL STAMP OF G.P. SURGERY OR HOSPITAL
(DD/MM/YY)
HOW MANY WEEKS PREGNANT

PATIENTS NAME
SIGNATURE OF AUTHORISED OFFICIAL

5 MEMBER´S AUTHORISATION AND SIGNATURE
I GIVE MY CONSENT TO ALL PROCESSING OF PERSONAL AND SENSITIVE DATA. I DECLARE THAT ALL THE INFORMATION INCLUDED IS ACCURATE, TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I AGREE THAT HEALTH SHIELD CAN CONFIRM THE DETAILS WITH THE HEALTHCARE PROVIDER. I UNDERSTAND THAT HEALTH SHIELD MAY END MY MEMBERSHIP IF MY CLAIM IS FOUND TO BE FRAUDULENT.
DATE (DD/MM/YY)	YOUR SIGNATURE
FRAUDULENT CLAIMS: HEALTH SHIELD ARE COMMITTED TO PREVENTING FINANCIAL CRIME AND WE WILL REPORT TO THE POLICE ALL INSTANCES OF FRAUD OR ATTEMPTED FRAUD.

CLAIMS CHECKLIST

HAVE YOU SIGNED AND DATED SECTION 5?

HAVE YOU COMPLETED SECTION 2?

HAVE YOU INCLUDED YOUR MEMBERSHIP NUMBER?

HAS THE HOSPITAL CHECKED AND SIGNED
SECTION 3?

PLEASE RETURN TO

PLEASE RETURN THIS FORM, ALONG WITH ALL NECESSARY ADDITIONAL INFORMATION AND RECEIPTS TO HEALTH SHIELD. WE AIM TO TURNAROUND ALL RECEIPT BASED CLAIMS WITHIN TWO WORKING DAYS.

Health Shield Friendly Society Ltd, Electra Way, Crewe Business Park, Crewe, Cheshire CW1 6HS

Health Shield Friendly Society Ltd. Electra Way, Crewe Business Park, Crewe, Cheshire, CW1 6HS
Telephone: 01270 588555 Fax: 01270 251366 Opening hours: 8.00am to 6.00pm, Monday to Friday
Email: info@healthshield.co.uk Website: www.healthshield.co.uk Established in 1877.
Authorised and regulated by the Financial Services Authority. As part of our on-going quality control programme,
calls may be monitored or recorded.

Print Claim Form
PLEASE REFER TO YOUR MEMBERSHIP PLAN WHEN CLAIMING BENEFITS. PLEASE MAKE SURE YOU COMPLETE YOUR MEMBER NUMBER AS YOUR CLAIM COULD BE DELAYED. TICK AND/OR COMPLETE THE APPROPRIATE BOXES WHERE APPLICABLE PLEASE PRINT THIS FORM AT 100% SCALE ON YOUR PRINTER SETTINGS SO IT PRINTS OVER 3 PAGES