Professional Documents
Culture Documents
Before you complete this claim form: did you know that you can claim online at bupa.com.au*? (terms and conditions available at bupa.com.au) if youre making an over-the-counter claim on your membership at a Bupa centre, you dont need to fill in this form. *not available to members of Overseas Student Health Cover For more claiming options, see Just before you send. 1. Please complete this form using black ink and write within the boxes in CAPITAL LETTERS. Mark appropriate answer boxes with a cross. Start at the left of each answer space and leave a gap between words. Please do not staple. 2. Please complete all details that are relevant to you on all pages of this form. 3. Read the declaration and sign all the relevant signature panels.
X Yes
X No
Date of birth
First name
D D M M Y
Mobile phone number Postcode Do you wish this address to be recorded as your payment address? Fax number
Yes
No Email address
BSB number -
Please enclose original accounts/receipts. If a receipt is not provided for Medical claims, claims will be made payable directly to the provider. All accounts/receipts and any documents supporting your claim will be retained by Bupa. Should you wish to retain a copy of any accounts/receipts relating to your claim, we recommend you keep a copy of these before submitting your claim.
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Section E: Claim details (claims must be made within 2 years of the date of service)
Provider paid? Y/N Patient name 1. 2. 3. 4. Name of service provider (eg Dr A P Jones)
X X X X
Type of accident Yes. If yes, which hospital?
D D M M Y X
to
D D M M Y X
No
Is the service claimed resulting from an accident? Yes. If yes, date of accident
No
D D M M Y
No
D D M M Y
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Please mail your claim form to: Bupa Reply Paid 990 ADELAIDE SA 5001 If you are on an Overseas or Overseas Student Health Cover, you can email your claim to corporateclaims@bupa.com.au or fax to 1300 365 848. If you would like any assistance, please call us on 134 135.
Click through to bupa.com.au The member services area* at bupa.com.au allows you to view and update your membership details online or find answers to many of your questions at the click of a button. Simply login at bupa.com.au *not available to members of Overseas Student Health Cover
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