Reg 2-Primary Care Claim Form-31 Oct 2008

Please use one claim per member
Mayfair Healthcare Scheme
Claim Form for: Vision Care, Dental, Prescription and General Practitioner Charges
This claim form is only to be used when claiming benefit for the above services. Please check the Guidelines
For Completion on the reverse of this form. If your claim is for medical advice or treatment please call the
Mayfair Help Desk on 0800 294 5637.
You may print out this form and complete it or enter your data directly on screen, using the tab key to move
between fields, and then print it.
Member details
Title
Date of
birth
First name
D
Surname
Y
Mayfair I.D. no.
Home
address
Postcode
Telephone
number
Email
Patient details
Date of
birth
Title
First name
Surname
Total cost of invoices/receipts

attached
Have the invoices/receipts been paid by you?
Treatment
Please indicate the type of treatment received making sure all sections of this form are completed.
Please tick against each option and list the invoices/receipts being submitted for assessment.
Dental
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Cost
Cost
Cost
Cost
Cost
Optical
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Cost
Cost
Cost
Cost
Cost
Conditions that
necessitate
treatment:
Details of services
supplied (e.g. dental
care, spectacle
lenses, spectacle
frames, out-patient
drugs etc).
General practitioner
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Cost
Cost
Cost
Cost
Cost
Prescription charges
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Cost
Cost
Cost
Cost
Cost
Yes
No
Members declaration
Signature of member
Date
Please print name
To be completed by the Patient or (if the Patient is under 18 years of age) the Patients Parent or Guardian
In order to determine whether your healthcare plan will cover the cost of your treatment, we might need to obtain a medical report
from your healthcare practitioner. Before your healthcare practitioner can give us medical information about you, you must give your
consent. Before giving your consent, you should be aware of your rights.
1. You may withhold your consent to the application being made or to the report being supplied to us.
2. You may see the report before it is sent to us. You must ask your healthcare practitioner for a copy within 21 days of the date on
which we request the report, which we will notify to you.
3. You may ask your healthcare practitioner for a copy of the report at any time up to six months after the date of the report.
4. You may ask your healthcare practitioner to amend any part of the report, which you consider to be incorrect or misleading. If the
healthcare practitioner does not agree with your request, you may attach your comments to the report.
5. Your healthcare practitioner may withhold the report from you, even though you have requested a copy, if he considers that it would
be harmful to your physical or mental health or if it contains information about a third party who has not consented to its disclosure.
If we require a medical report to enable us to consider your claim and you have not given your consent to us obtaining such a report, it
is unlikely that your healthcare plan will cover the cost of your treatment.
Patients declaration
Having been made aware of my statutory rights, I hereby consent to BCWA Administration Services Limited seeking medical
information from any healthcare practitioner who has attended me at any time concerning anything that affects my physical or mental
health and I authorise any such healthcare practitioner to disclose such information to the BCWA Administration Services Limited.
Signature
Date
Please print name
The patient
I confirm I am (please tick one)
The patients parent
The parents guardian
Guidelines for completion
Please complete this form to claim reimbursement for Vision Care, Dental, Prescription and General Practitioner charges.
Claims for reimbursement of prescription charges should be accompanied by a copy of the prescription and associated receipt.
Please ensure your GP, specialist or provider completes the declaration below.
Please use one claim form per family member.
Please obtain separate invoices/receipts for each family member.
Please ensure that your practitioner or pharmacy completes and stamps the declaration below.
In the case of a vision care or dental claim, please obtain a detailed receipt for services received.
Once completed, please submit the claim form and invoices/receipts to:
Mayfair Help Desk

Medisure
100 Temple Street
Bristol BS1 6EN
A reimbursement cheque up to the scheme limits will be forwarded to your home address.
If your claim is for medical advice or treatment, please contact the Mayfair Help Desk on 0800 294 5637.
To be completed by the patients healthcare practitioner
Signature
Practice/
Pharmacy
stamp
Name
D
Y
SP0083/1108
Date

Reg 2-Primary Care Claim Form-31 Oct 2008

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Reg 2-Primary Care Claim Form-31 Oct 2008

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Please use one claim per member

Mayfair Healthcare Scheme

Mayfair I.D. no.

Total cost of invoices/receipts

Have the invoices/receipts been paid by you?

Please print name

Please print name

I confirm I am (please tick one)

The patients parent

The parents guardian

Guidelines for completion

Please obtain separate invoices/receipts for each family member.

Mayfair Help Desk

To be completed by the patients healthcare practitioner

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