Overseas Student Health Cover - Claim Form (Page 2 of 2) in pdf

Claim form

Complete this section if you saw a doctor

Did you know?

or went to hospital

Direct Billing Medical Providers

Allianz Global Assistance

has an extensive network of medical

Have you had this or a related condition before?

yes

providers around Australia – show your valid OSHC card and you do

If yes, please provide details (dates, name & address of treating

not have to make a claim. The bill is sent directly to

Allianz Global

Assistance

doctors/s, treatment etc):

(some medical providers may charge a co-payment

which can not be claimed). Find your local Direct Billing Medical

Providers online at

Cash Claims

Our cash claims service is available on-campus at most major

Institutions. See your local Client Service Representative to process

claims under $105 and provide you with vouchers redeemable for

cash at Australia Post outlets. Check our website for details of times

and locations of Client Service Representatives.

Payment to Australian bank account by EFT

Online Services –

Visit our website to:

(Electronic Funds Transfer)

Submit online claims (be sure to send in your original receipts with

•

Please provide correct bank account details to ensure prompt payment

your claim number)

(only complete if you have already paid the account and have attached

Renew your policy

•

Order replacement membership cards

original tax invoices and receipts). If correct bank details are not

•

View our helpful information video

•

provided, a cheque will be sent to your Australian postal address.

Read health and wellbeing information

•

Name of financial institution:

24 Hour Emergency Helpline – 1800 814 781

Emergency access to medical, legal and interpreting services

Name of account holder:

Waiting Periods

BSB number (6 digits):

Under both Standard Cover and Essentials Cover, the waiting period

in relation to a pre-existing condition (other than a psychiatric

Account number (up to 9 digits):

pre-existing condition) is 12 months.

In addition:

Declaration

Under Standard Cover, there is a waiting period of two months

•

for psychiatric pre-existing conditions and of 12 months for

I declare that all statements and particulars contained on this claim

pregnancy related conditions.

form are true and correct.

Under Essentials Cover, there is a waiting period for pregnancy

•

related conditions if your visa is of less than three months duration.

Allianz Global Assistance

I authorise

to contact the hospital or

All waiting periods commence from the later of the following:

provider of any service for further clarification of details relating to

(i) the date you (or your Dependant) arrived in Australia

this claim if necessary.

(as the case may be); or

Signature:

(ii) if you are an onshore applicant who previously did not hold a

student visa, the date your student visa was granted.

You cannot claim for costs arising during the relevant waiting period

Date:

_ _ /_ _ /_ _ _ _

if such costs arise from a pre-existing condition, psychiatric condition

or pregnancy related condition as applicable. See your policy

document for further details in relation to waiting periods.

Office use only

Incident #:

Protection of your personal information

The information that you provide is collected for the purpose of issuing you with

OSHC insurance, determining any claims you may make on this policy (including

Allianz Global Assistance will endeavour to process your claim

complying with regulatory requirements in relation to OSHC). The information

within 10 working days of receiving a completed claim form and

may be disclosed to education providers, health fund providers, underwriters,

all original documents.

marketing and service provider intermediaries, government departments,

medical practitioners, claims assessors, investigators, medical assistance providers,

associated companies, hospitals and other international assistance providers in

the course of providing these services and managing your policy, including to the

Please return completed form to:

Department of Immigration and Citizenship in the event that receive a premium

refund for whatever reason or cancel your OSHC policy. By applying for this

Allianz Global Assistance OSHC

insurance you also agreed, in respect, of any claim, to allow us to provide details of

your cover and other information from any healthcare provider who provides you

Locked Bag 3001 Toowong QLD 4066

with treatment in order to process your claim.

Phone:

13 OSHC (13 6742)

Allianz Global Assistance advises that the information will only be used for those

Fax:

+61 7 3305 7009

purposes. If you would like to gain access to any of the information you have

Email:

.au

provided, please contact Allianz Global Assistance.

Allianz Global Assistance Overseas Student Health Cover policies are authorised under a Deed entered into between Lysaght Peoplecare Limited and the Australian Government

through the Department of Health and Ageing. Allianz Global Assistance OSHC is managed by AGA Assistance Australia Pty Ltd ABN 52 097 227 177. Lysaght Peoplecare Limited

ABN 95 087 648 753, a private health insurer under the Private Health Insurance Act 2007 (Cth) is the underwriter of Allianz Global Assistance OSHC policies.

Overseas Student Health Cover - Claim Form Page 2

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