Treatment Guarantee Form printable pdf download

Treatment Guarantee is not required in advance of emergency

Treatment

treatment, however either you, your physician, one of your dependants,

or a colleague need to inform us about the hospital admission within

48 hours of the event.

Our Helpline (+ 353 1 630 1301) can take Treatment Guarantee details

Guarantee Form

over the telephone if treatment is due to take place within 72 hours.

Please have as many details as possible to hand when calling, including

the contact details of your doctor.

Section 1

must be fully completed by (or on behalf of) the patient

For your convenience, this form (PDF and editable Word version) is

Section 2

must be fully completed by the doctor

available on our website:

PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS.

Failure to complete this form fully will delay our ability to guarantee your treatment as we may have to revert to you or the medical provider for further information.

The patient’s policy must be in force at the time of treatment. Please be advised that guarantee of payment is subject to the terms and conditions of the insurance policy

and also subject to the assessment of all relevant documentation received, or yet to be received, by Allianz Worldwide Care in respect of this medical condition.

PATIENT DETAILS

to be fully completed by (or on behalf of) the patient

Policy Number

Mr.

Mrs.

Ms.

Miss

Other

First name

Surname

Date of birth

Contact person

please specify who should be contacted regarding the progress of this Treatment Guarantee request

Name

Relationship to patient e.g. self, spouse/partner, parent

Telephone

(Country code)

(Area code)

Mobile telephone

(Country code)

(Network code)

Data Protection and release of medical records

References to information includes personal information given by you to us, in your Application, Claim or Treatment Guarantee Form and/or supporting documents/information

we collect in connection with products or services we provide. Allianz Worldwide Care, part of the Allianz Group, is the data controller for this information.

Uses: Personal information may be used for insurance administration (e.g. underwriting, claims handling, fraud prevention). We may use third parties to process data on our

behalf. Such processing, which may take place outside the European Economic Area (EEA), is subject to contractual restrictions regarding confidentiality and security in line with

Data Protection obligations.

Sensitive data: We need to collect sensitive data relating to you (e.g. health details), to assess insurance terms and/or administer claims.

Disclosure: We may share your information with our agents, members of the Allianz Group, other insurers and their agents, service providers, any intermediary acting on your

behalf or governing/regulatory bodies (of which we are a member or by which we are governed). In certain circumstances, we may use private investigators to investigate a claim

you have submitted.

Retention: We are obliged to retain your records for six years from the date the insurance relationship ends. We will not retain your data for longer than necessary and will hold it

only for the purposes for which it was obtained.

Representation and Consent: By signing this form you confirm that you have the authority to act on behalf of your dependants in respect of all personal information you provide

to us, and that you consent to the disclosure, processing, usage and retention of this information in relation to yourself and on behalf of your dependants.

Access: You have the right to request and receive a copy of your personal data held by us. If you wish to do this, please write to the Data Protection Officer at the address provided

on this form or via .

Call recording: Calls to our Helpline will be recorded and may be monitored for training, quality and regulatory purposes.

I agree to waive any rights that I may have to medical secrecy/confidentiality in respect of my medical information and I authorise my medical practitioner, health professional or

other relevant medical establishment to provide relevant medical information relating to me, if requested by Allianz Worldwide Care, its medical advisers, its appointed

representatives, or to any third party expert(s) in case of disputes, subject to any legal restrictions which may apply.

If a minor was treated, a parent or guardian should sign this section.

Patient’s signature

Date

Allianz Worldwide Care SA, acting through its Irish Branch, is a limited company governed by the French Insurance Code. Registered in

France: No. 401 154 679 RCS Paris. Irish Branch registered in the Irish Companies Registration Office, registered No.: 907619, address:

15 Joyce Way, Park West Business Campus, Nangor Road, Dublin 12, Ireland.