FOR OFFICE USE ONLY



PLEASE REFER TO YOUR MEMBERSHIP PLAN WHEN CLAIMING BENEFITS.
PLEASE MAKE SURE YOU COMPLETE YOUR UNIQUE REFERENCE
NUMBER AS YOUR CLAIM COULD BE DELAYED.
TICK AND/OR COMPLETE THE APPROPRIATE BOXES WHERE APPLICABLE.
1 MEMBER’S PERSONAL INFORMATION
TITLE      SURNAME      FORENAME(S)  
DATE OF BIRTH    (DD/MM/YYYY)   UNIQUE REFERENCE NUMBER  
FULL POSTAL ADDRESS INCLUDING POSTCODE
CONTACT EMAIL ADDRESS CONTACT TELEPHONE NUMBER
  PLEASE TICK IF YOU DON'T WISH YOUR DIRECT CREDIT NOTIFICATION TO BE SENT BY EMAIL
2 TYPE OF BENEFIT YOU CAN USE THIS CLAIM FORM FOR MORE THAN ONE TYPE OF BENEFIT
I AM CLAIMING THE   BENEFIT
CHILD'S NAME DATE OF BIRTH
 (DD/MM/YYYY)
CHILD'S NAME DATE OF BIRTH
 (DD/MM/YYYY)
BENEFIT CLAIMED FOR:
YOU      PARTNER     DEPENDANT CHILD  
PARTNER'S NAME DATE OF BIRTH
 (DD/MM/YYYY)
3 METHOD OF BENEFIT PAYMENT
HOW DO YOU WISH THIS PAYMENT TO BE MADE?  CHEQUE (A)   EXPRESS DIRECT CREDIT (B)
(A) CHEQUES TO BE MADE PAYABLE TO (IF DIFFERENT FROM THE MEMBER)
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
4 HOSPITAL INPATIENT, DAY-CASE ADMISSIONS AND PARENTAL HOSPITAL STAY
YOU MUST FILL IN SECTION 4 YOURSELF. THIS MUST THEN BE CHECKED, SIGNED AND STAMPED AT THE HOSPITAL, REGISTERED TREATMENT CENTRE OR HOSPICE. PLEASE ALLOW 2 TO 3 WEEKS WHEN CLAIMING THESE BENEFITS.
TITLE      SURNAME      FORENAME(S)  
WAS ADMITTED AS AN INPATIENT OR WAS ADMITTED AS A DAY-CASE PATIENT
OR PARENT ACCOMPANYING CHILD OVERNIGHT (A SEPARATE FORM MUST BE COMPLETED FOR THE CHILD)
NAME OF HOSPITAL
PATIENT'S HOSPITAL NUMBER IF KNOWN
ADMISSIONS DATE ADMITTED DATE DISCHARGED NUMBER OF DAY CASE
/OVERNIGHT STAYS
1ST ADMISSION  (DD/MM/YYYY)  (DD/MM/YYYY)
2ND ADMISSION  (DD/MM/YYYY)  (DD/MM/YYYY)
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
5 FOR MATERNITY - ANTENATAL APPOINTMENT CLAIMS ONLY
(THIS SECTION MUST BE COMPLETED BY THE G.P. SURGERY, HOSPITAL, REGISTERED CLINIC OR SERVICE)
DATE OF SCAN OFFICIAL STAMP OF G.P. SURGERY, HOSPITAL,
REGISTERED CLINIC OR SERVICE
PATIENTS NAME
SIGNATURE OF AUTHORISED OFFICIAL
6 MEMBER'S EMPLOYMENT DETAILS (IF APPLICABLE)
COMPANY PAY OR EMPLOYEE NUMBER
7 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.
DATE YOUR SIGNATURE
FRAUDULENT CLAIMS: IN THE INTEREST OF OUR MEMBERS, DETECTION OF FRAUDULENT CLAIMS COULD RESULT IN LEGAL ACTION.
CLAIMS CHECKLIST
HAVE YOU INCLUDED YOUR UNIQUE REFERENCE NUMBER?
IF CLAIMING MATERNITY-ANTENATAL APPOINTMENT
BENEFIT, HAS SECTION 5 BEEN COMPLETED?
ARE YOU SENDING A HOSPITAL CLAIM FORM? PLEASE CHECK THE FORM HAS BEEN FULLY COMPLETED
HAVE YOU SIGNED AND DATED SECTION 7?
Investor in People Health Shield Friendly Society Ltd. Electra Way, Crewe Business Park, Crewe, Cheshire, CW1 6HS
Telephone: 01270 588555 Fax: 01270 251366 Telephone 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.

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