Health Shield - Receipt 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 RECEIPT BASED CLAIMS A SAMPLE RECEIPT IS SHOWN AT THE BOTTOM OF THIS FORM

please ensure that you enclose all the relevant, original receipts with this claim form. If you have had a series of treatments the receipt must show the date and cost for each treatment.

I AM CLAIMING FOR:

you	partner	child	date of birth	benefit	amount paid	date of treatment	medical reason for treatment




IF APPLICABLE, I ENCLOSE A COPY OF MY NEWBORN BABY´S FULL BIRTH CERTIFICATE						For dental accident claims please also see section 4

3 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
		--

4 FOR DENTAL ACCIDENT CLAIMS ONLY (THIS SECTION MUST BE COMPLETED BY YOUR DENTIST)

DATE OF ACCIDENT

CAUSE OF ACCIDENTOFFICIAL STAMP OF DENTIST

(DD/MM/YY)	Please enclose the receipt from the dentist confirming the treatment has been caused by a direct blow to the head
PATIENT´S NAME

SIGNATURE OF DENTIST

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 ATTACHED THE RELEVANT RECEIPTS, CERTIFICATES OR PAPERS ?

HAVE YOU INCLUDED YOUR MEMBERSHIP NUMBER ?

HAVE YOU COMPLETED SECTION 3?

PLEASE RETURN TO

SAMPLE RECEIPT FOR GUIDANCE

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 2 PAGES