Authorisation For Release Of Medical Information Form
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1Authorisation for Release
of Medical Information Form
Please complete and sign the following authority for the release of Your medical information. We ask You also to refer to section 3.6 of Your members’
handbook which outlines the additional information You may be asked to provide in the event of a claim. Please note that if You do not allow Us
reasonable access to this information, We may not be able to process Your claim.
Member Details
Member name:
Membership number:
Date of birth (dd/mm/yyyy):
/
/
Medical facility details
Medical facility/treating Medical Practitioner:
Email:
Telephone number:
Fax:
Medical details
I/the member named above authorise the above medical facility/treating Medical Practitioner to release the following medical records and confidential
information to AXA Insurance (Gulf) B.S.C. (c) or to its authorised representative
:
Complete record
Records of care from (dd/mm/yyyy)
/
/
to (dd/mm/yyyy)
/
/
only
Records of care concerning the following Medical Condition(s):
Other. Please specify:
Authorisation to confer with above named treating Medical Practitioner orally about information in my medical record
Authorisation
I understand that I may have access to the medical information requested and may equally decline its release (preventing the assessment of my claim)
and hereby consent to AXA Insurance (Gulf) B.S.C. (c) or to its authorised representative obtaining medical information from the above medical
facility/treating Medical Practitioner.
A photocopy or facsimile of this authorisation shall be considered as effective and valid as the original.
Signature of member/authorised representative:
Date (dd/mm/yyyy):
(parent/legal guardian/next of kin)
/
/
Note: AXA Insurance (Gulf) B.S.C. (c) will not pay for the release of any medical reports/records.
Return this form by email to MEAService@worldcare.ae
Plans are underwritten by AXA Insurance (Gulf) B.S.C. (c). Dubai Branch: PO Box 32505, Dubai, UAE.
Registered in the Insurance Companies Register under the Federal Law No.9 of 1984.
Now Health International (Services) FZ LLC administers plans on behalf of AXA Insurance (Gulf) B.S.C. (c), PO Box 502163, Dubai, UAE.
Plans are reinsured by AXA PPP healthcare Limited, Registered office: 5 Old Broad Street, London EC2N 1AD, United Kingdom.
WC UAE 28045 08/2015
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