Send your claim & receipts/accounts to:
Email: [email protected]
Phone: 1800 148 626
Fax: 1300 673 406
Post: Locked Bag 25, Wollongong NSW 2500
Web: www.onemedifund.com.au
Claim Form
J O H N
PLEASE USE A BLACK PEN AND PRINT IN CAPITAL LETTERS INSIDE THE BOXES. EXAMPLE:
1. YOUR DETAILS
Contributor Number
First Name
Middle Name
PRINT
Service Type
Code
AcupunctureACU
ChiropracticCHI
Dental (use 3 number
item code from your receipt)
Surname
Massage (remedial)
REM
NaturopathNAT
OpticalOPT
OsteopathyOST
PharmacyPHA
PhysiotherapyPHY
PodiatryPOD
2. CHANGE OF CONTACT DETAILS or PAYMENT METHOD Click the checkbox OR leave it blank if unchanged.
If your service isn’t listed or you’re not sure,
just leave this blank.
I have changed my contact details
I would like my claim paid into a new bank account
(If yes, please complete section 5 on the reverse)
(If yes, please complete section 6 on the reverse)
3. CLAIM DETAILS
Please include itemised receipts / accounts with your claim form
Patient First Name
Patient DOB (dd/mm/yy)
Service Date (dd/mm/yy)
Cost of Service ($)
Provider Surname
Provider Number
Service Type
E.G.
J O H N 2 1 0 7 8 2 0 8 1 1 1 0 0 1 2 5 .. 5 0 S M I T H 0 1 1 2 6 3 2 B C H I
1
.
2
.
3
.
4
.
5
.
6
.
7
.
8
.
9
.
10
.
5. CHANGE OF CONTACT DETAILS (Only complete if your contact details have changed)
Street Address
Suburb
Email Address
Home Phone Number
State
Mobile Number
-
BSB Number
Fax Number
-
6. DIRECT CREDIT DETAILS (Only complete if your bank details have changed)
Bank Name
Post Code
Account Name
Account Number
-
7. MAKING A CLAIM
Simply choose the option that best suits you. You can swipe your onemedifund card at the service provider or claim via email, web, fax or post.
Email:
[email protected]
Phone: 1800 148 626
Fax:
1300 673 406
Post:
Locked Bag 25, Wollongong NSW 2500
Web: www.onemedifund.com.au
We can deposit your benefits straight into your bank account or mail you a cheque. 8.INSTRUCTIONS
Receipts/accounts must accompany all claim forms. They should be fully itemised including the patients’ name, and the name, address and details of your provider. Benefits
are only paid on claims that are less than two years old (24 months).
Please note - Receipts will not be sent back with your remittance advice but will be filed electronically in your member file. The remittance advice will detail all costs from your
claims and the benefits paid. If you need a copy of your receipts in the future they can be provided to you at no charge.
9. DECLARATION & PRIVACY STATEMENT
I declare that:
• I authorise the onemedifund to use my personal information in accordance with the Privacy Policy.
• I have the authority to supply the personal information of the people listed on this claim form.
• The services listed on this claim are not claimable from other sources e.g. Medicare
Australia,workers compensation, third party or action for damages. If so, and the fund pays
benefits, I agree to reimburse the onemedifund.
• I authorise any medical practitioner, health service provider or hospital to provide information about
anyone listed on this claim form, to enable this claim to be assessed.
• I certify that all information related to this claim is true and correct.
National Health Benefits Australia (trading as onemedifund). A registered private health insurer. ABN 67 122 255 396
Privacy Policy
onemedifund collects personal information for a number of purposes. onemedifund is committed to protecting
your personal information and complying with the requirements of the Privacy Act. Personal information is
primarily collected for the purpose of processing health benefit claims for contributors and dependants.
For more information about the onemedifund Privacy Policy, please call 1800 148 626.
Contributor Signature
Date (dd/mm/yy)