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 POST CODE
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
I ATTACH ORIGINAL RECEIPTS FOR £
BENEFIT CLAIMED FOR:
YOU
PARTNER
DEPENDANT CHILD
IF APPLICABLE, I ENCLOSE A COPY OF MY NEWBORN BABY'S
FULL
BIRTH CERTIFICATE
IF CLAIMING THE PHYSIOTHERAPY ETC, SPECIALIST CONSULTATION, HEALTH AND WELLBEING OR FAMILY PLANNING BENEFIT, PLEASE GIVE THE MEDICAL REASON
FOR THE TREATMENT BELOW.
PARTNER'S NAME
DATE OF BIRTH
(DD/MM/YYYY)
CHILD'S NAME
DATE OF BIRTH
(DD/MM/YYYY)
CHILD'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 FOR DENTAL ACCIDENT CLAIMS ONLY
(THIS SECTION MUST BE COMPLETED BY YOUR DENTIST)
DATE OF ACCIDENT
CAUSE OF ACCIDENT
PLEASE ENCLOSE THE RECEIPT AND SAY HOW MUCH
WAS PAID
PATIENTS NAME
SIGNATURE OF DENTIST
5 MEMBER'S EMPLOYMENT DETAILS (IF APPLICABLE)
COMPANY
PAY OR EMPLOYEE NUMBER
6 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?
HAVE YOU INCLUDED A FULL BIRTH CERTIFICATE FOR THE BABY IF CLAIMING MATERNITY BENEFIT?
HAVE YOU ATTACHED ALL THE RELEVANT ORIGINAL RECEIPTS FOR EACH PERSON?
ARE YOU CLAIMING THE DENTAL ACCIDENT BENEFIT?
IF YES, HAS YOUR DENTIST COMPLETED AND SIGNED
SECTION 4?
IF CLAIMING THE PHYSIOTHERAPY ETC, SPECIALIST CONSULTATION, HEALTH AND WELLBEING OR FAMILY PLANNING BENEFIT, HAVE YOU COMPLETED SECTION 2 FULLY STATING THE MEDICAL REASONS FOR THE TREATMENT AND/OR TESTS?
HAVE YOU SIGNED AND DATED SECTION 6?
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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