Claim form

Important information
For quicker handling of your claim, simply log in to your MembersWorld account and either complete a digital version of this claim
form, or complete the mandatory fields as shown on the ‘submit a claim’ section. Alternatively, you can return this form with original
or copied invoices by post to: International Health Insurance, Bupa PO Box 24256, Melbourne, VIC 3001.
To prevent delay with the handling of your claim, please complete all sections of the claim form clearly. The form should be returned
to us within 2 years of the initial treatment date. Please write clearly in black ink and BLOCK CAPITALS.
Please complete a new / separate claim form for:

¡ each patient ¡ each in-patient / day-stay case ¡ each medical condition ¡ each reimbursement currency

We are unable to return original documents, but we will be happy to provide certified copies on request.
Before submitting the claim please refer to the checklist at the end of the form.

1 Patient’s details (to be completed by the person undergoing treatment)

Patient membership number: Group name (if applicable):

BI - - -

Title:

First name:

Family name:

Date of birth: D D M M Y Y Y Y Age last birthday:

Correspondence address:

Building:

Street:

Town / city:

Post / Zip code: PO Box:

Region:

Country:

Email:

Telephone (Please include country code, area code and number):

If posting your claim to us, would you like an email acknowledgement to confirm receipt of your claim? Yes No
If yes to email, please ensure your email address is given clearly above.

Do you have a residence in the U.S.? Yes No

Is this your permanent residency address? Yes No Do you have a residence in the U.S.? Yes No

Do you have a residence in the U.S.? Yes No

If this country was Australia, to confirm this treatment is not or could not be covered by your Medicare benefits please select here Yes No

Are you currently, or have you been eligible in the past 5 years, for Medicare Benefits? Yes No

Please note: If you have received treatment in Australia, you should only claim under this plan if the treatment is not or could not
be covered by Medicare.
Please check your Medicare benefits.
 (all sections must be completed by the Medical Practitioner in overall charge of the patient’s
2 Claim/medical details treatment where possible, otherwise it should be completed by member)

In which country did the treatment take place?

What is the currency of the invoice?

What is the total amount of the claim?

Medical Details:

Reason for treatment / visit to medical practitioner, such as your symptoms and diagnosis if known:

Is the treatment related to: Wellness/preventative Maternity Oncology Dental

Onset date when symptoms first noticed by patient: D D M M Y Y Y Y

When did the patient first see a doctor?: D D M M Y Y Y Y

Details of treatment received, including operations and medications:

Medical Practitioner’s details:

Name:

Speciality/Qualifications:

Address:

Email:

Telephone (Please include country code, area code and number):

Hospital admission details (if applicable):

Admission date: D D M M Y Y Y Y Discharge date: D D M M Y Y Y Y

Hospital name:

Address:

Email:

Telephone (Please include country code, area code and number):

Medical practitioner’s signature

Print Name: Date: D D M M Y Y Y Y

The hospital should complete this section if there were no charges for your overnight admission, and your plan includes a cash benefit

I confirm that
was in hospital  from           to
And this admission was free of charge

The hospital needs to stamp this claim form here:

4 Payment details

Important information

We can settle claims in over 80 currencies. This must be in one of the following; (i) the currency in which you pay your premium (ii)
the currency of the invoices you send us or (iii) the currency of your bank account.

Who would you like us to pay? (select one only)

Group/Company (enclose proof

Please complete either Section A or Section B

Bank name:

SWIFT / BIC code *:

BSB number: -

Account number / IBAN *:

Account name / payee:

Currency for the transfer:

Bank address:

Post / Zip code:

Country:

*To process your payment as quickly and securely as possible, we strongly recommend this option as a preferred payment method.
Please provide both your IBAN and the SWIFT code of your bank branch. Your bank will be able to provide you with this information
if necessary.
We recommend that bank transfers are made in the currency of your bank account. If you submit a claim and have asked us to pay you, your benefit will be paid less the amount of
deductible or co-insurance applicable to your plan. If you have asked us to pay the provider, and an annual deductible or co-insurance applies to your cover, the shortfall will be collected
using your Direct Debit, Electronic bank transfer or BPAY. If you are part of a company plan, we will send payment to the medical provider for the eligible claim. We will deduct from this
payment the remaining annual deductible or co-insurance on your membership. You are responsible for paying any shortfall to the provider after your claim has been assessed and paid.
To find out if you have a co-insurance or deductible on your plan, please refer to your membership certificate. To find out more about how co-insurances and deductibles work please refer to
your membership guide.

Section B - Payment by cheque

In which currency would you like us to pay the cheque (please select one only)

Currency of your invoices Currency of your premiums Currency of your bank account

Other, please specify:

Cheques payable to members will be sent by post to the correspondence address provided on the front page
5 Third party insurers

Are some of the costs recoverable from someone else (for example, state insurer or a person / organisation involved in an accident?): Yes No

Name:

Address:

Email:

Telephone (please include country code, area code and number):

6 Your consent to obtain a medical report

Important information

In order to process your claim, we may need to apply for a medical report from any doctor who has
attended you. To apply, we need you to give your consent by signing the declaration below.
Please read this section carefully, as it sets out your rights under the Access to Medical Reports Act 1988 and the Access to Personal
Files and Medical Reports (NI) Order 1991.
If you receive treatment in the UK, you can choose from three course of action.
1. You can give your consent without asking to see the doctor’s report before it is sent to us. The report will then be sent directly to us
by the doctor.
2. You can give your consent, but ask to see any report before it is sent to us, in which case you will have 21 days, after we notify you
that we have requested a report from the doctor, to contact your doctor to make arrangements to see the report. If you fail to contact
the doctor within 21 days, he will be entitled to send the report direct to us. If however you contact your doctor with a view to seeing
the report, you must give the doctor written consent before he can release it to us. You may ask your doctor to change the report if
you think it is misleading. If your doctor refuses, you can insist on adding your own comment to the report before it is sent to us.
Should you give your consent to us obtaining a report without indicating that you wish to see it, you can change your mind by
contacting your doctor before the report is sent to us, in which case you will have the opportunity to see the report and ask the
doctor to change the report or add your comments before it is sent to us, or withhold your consent for its release.
3. You can withhold your consent but, if you do, please bear in mind that we may be unable to accept your claim.
Whether or not you indicate that you wish to see the report before it is sent, you have the right to ask your doctor to let you see
a copy, provided that you ask him within six months of the report having been supplied to us.
Your doctor is entitled to withhold some or all of the information contained in the report if (a) he feels that it may be harmful to you
or (b) it would indicate his intentions in respect of you or (c) would reveal the identity of another person without their consent (other
than that provided by a health professional in their professional capacity in relation to your care). Your doctor may also make
a reasonable charge for his services.
The undersigned authorises and requests any hospital, specialist, physician or other health provider to furnish Bupa or its duly
authorised agent acting on their behalf with such information as Bupa or that agent may seek from them in connection with any
treatment or other services provided to me or my dependant for the purpose of your insurer IAL or Bupa Global considering this claim
If you are receiving treatment in the UK, by signing this form you are confirming that:
I have been advised of my rights under the Access to Medical Reports Act 1988 and the Access to Personal Files and Medical Reports
(NI) Order 1991.

If you receive treatment in the UK please indicate below if you wish to see a copy of the medical report before it is sent to Bupa:
I do wish to see a copy of any medical report before it is sent to Bupa.
I do NOT wish to see a copy of any medical report before it is sent to Bupa.

7 Privacy notice
Bupa international private medical insurance is underwritten in You can find more details in our full privacy notice available at:
Australia by Insurance Australia Limited ABN 11 000 016 722 (IAL), www.bupaglobal.com/privacypolicy. If you do not have access
AFSL number 227681. to the internet and would like a paper copy of the full privacy
notice, please contact the Bupa Global service team on
This product is distributed in Australia by Bupa HI Pty Limited +44 (0)1273 323 563. Alternatively, you can email or write to the
ABN 81 000 057 590 which is an Authorised Representative team via [email protected] or Bupa Global, Victory House,
of IAL. All policies and claims in relation to this product are Trafalgar Place, Brighton BN1 4FY, United Kingdom. If you have
administered by Bupa Insurance Services Limited of the any questions about how we handle your information, please
United Kingdom. contact us at [email protected]
Below is a summary of how each handle your personal Information about Bupa Global
and health information. In this privacy notice, references to “we” or “us” or “our”
Bupa Insurance Services Limited Privacy Notice are to Bupa Global. For company contact details, visit
We are committed to protecting your privacy when dealing www.bupaglobal.com/legal-notices
with your personal information. This privacy notice provides an 1. Scope of our privacy notice
overview of the information we collect about you and how we use This privacy notice applies to anyone who interacts with us in
and protect it. It also provides information about your rights. The relation to our products and services (“you”, “your”), in any way
information we process about you, and our reasons for processing (for example email, website, telephone, app).
it, depends on the products and services you use.
7 Privacy notice (continued)

2. Ways in which we obtain personal information 8. Transfers outside of the UK and the European Economic Area
We collect personal information from you and from certain third (EEA)
parties (for example those acting on your behalf, like brokers, We deal with many international organisations and use global
healthcare providers and so on). If you give us information about information systems. As a result, we transfer your personal
other people, you must make sure that they have seen a copy of information to countries outside of the UK and the EEA (the EU
this privacy notice and are comfortable with you giving us their member states and Norway, Liechtenstein and Iceland), for the
information. purposes set out in this privacy notice.
3. Categories of personal information 9. How long we keep your personal information
We process the following categories of personal information We keep your personal information in line with periods using the
about you and, if it applies, your dependants. This is standard criteria shown in the full privacy notice available on our website.
personal information (for example information we use to contact
10. Your rights
you, identify you or manage our relationship with you), special
You have rights to have access to your information and to ask us
categories of information (for example health information,
to correct, erase and restrict use of your information. You also
information about race, ethnic origin and religion that allows us to
have rights to object to your information being used, to ask us to
tailor your care), and information about any criminal convictions
transfer information you have made available to us, to withdraw
and offences (we may get this information when carrying out
your permission for us to use your information and to ask us
anti-fraud or anti-money-laundering checks or other background
not to make automated decisions which produce legal effects
screening activity).
concerning you or significantly affect you. Please contact us if
4. Purposes and lawful grounds of our processing personal you would like to exercise any of your rights.
information
11. Data Protection Contacts
We process your personal information for the purposes set out
If you have any questions, comments, complaints or suggestions
in our full privacy notice, including to deal with our relationship
about this notice, or any other concerns about the way in which
with you (including for claims and complaints handling), for
we process information about you, please contact us at
research and analysis, to monitor our expectations of performance
[email protected]. You can also use this address to
(including of health providers relevant to you) and to protect our
contact our Data Protection Officer.
rights, property, or safety, or that of our customers, or others. The
legal reason we process personal information depends on what We are regulated by the Information Commissioner’s Office
category of personal information we process. We normally process (www.ico.org.uk) who can be contacted at, Wycliffe House,
standard personal information on the basis that it is necessary so Water Lane, Wilmslow, Cheshire SK9 5AF, United Kingdom.
we can perform a contract, for our or others’ legitimate interests Tel: 0303 123 1113 (local rate) or 01625 545 745 (national rate).
or it is needed or allowed by applicable law. We process special You have a right to make a complaint to them or to your local
categories of information because it is necessary for an insurance privacy supervisory authority.
purpose, because we have your permission or as described in
our full privacy notice. We may process information about your Bupa Hi Pty Limited Privacy Notice
criminal convictions and offences (if any) if this is necessary to For full details about our Information Handling Practices, please
prevent or detect a crime. refer to our Information Handling Policy located at
https://www.bupa.com.au/-/media/Dotcom/Files/pdfs/bupa-
5. Marketing and preferences info-handling-policy
We would, on occasion, like to keep you informed of our products
and services which we consider may be of interest We collect personal information (including information about
to you. your health) in various ways to enable us to provide you with our
products and services.
Please tick if you would like us and other members of the
Bupa group to keep you updated about our products and For example, we collect personal information when you complete
services by post, telephone email and text. an application form at a retail centre or online, or when you
provide details over the phone. When you make a claim for
You will be able to opt out of receiving these communications benefits, we collect information from you and/or your provider
at any time by emailing [email protected] or by writing to about your treatment to enable us to administer and verify your
Bupa Global, Victory House, Trafalgar Place, Brighton BN1 4FY, claim. Where we collect information from you or your provider,
United Kingdom. we only collect the information we need to fulfil the relevant
purpose. We may also collect information about you through
6. Processing for Profiling and Automated Decision Making
our agents.
Like many businesses, we sometimes use automation to provide
you with a quicker, better, more consistent and fair service, as There are a number of laws which require us to collect
well as with marketing information we think will be of interest information about you, including the Private Health Insurance
(including discounts on our products and services). This may Act 2007.
involve evaluating information about you and, in limited cases,
using technology to provide you with automatic responses or If you do not provide us with the information we require, we will
decisions. You can read more about this in our full privacy notice. not be able to pay to provide you with the products or services
You have the right to object to direct marketing and profiling you have requested. You have the right at any time to request
relating to direct marketing. You may also have rights to object reasonable access to the information we hold about you. We
to other types of profiling and automated decision-making. reserve the right to charge for retrieval of your information.

7. Sharing your information In providing you with our products and services, we may disclose
We share your information within the Bupa Group, with relevant personal information to third parties, including:
policyholders (including your employer if you are covered Disclosure to other persons or organisations engaged by us or
under a group scheme), with funders who arrange services on acting on our behalf in relation to the provision of our products
your behalf, those acting on your behalf (for example brokers and services, or the operation of our business. When we engage
and other intermediaries) and with others who help us provide a third party, we require that party to handle your personal
services to you (for example healthcare providers) or who we information in accordance with all relevant privacy laws,
need information from to handle or check claims or entitlements and solely for the purposes of their engagement;
(for example professional associations). We also share your
information in accordance with the law. You can read more about Where laws require or allow us to disclose personal information,
what information may be shared in what circumstances in our full for example disclosure to the Department of Health and Ageing,
privacy notice. Medicare Australia, other government or regulatory bodies,
tribunals and courts of law;
When a hospital or provider helps administer a claim that
has been made for hospital or ancillary items or services
(e.g. hospitals, doctors and other ancillary providers).
7 Privacy notice (continued)
If you transfer to or from another health insurer, we may be We may share this information with companies within our group,
required to disclose your information to that insurer. our agents, authorised representatives, government and law
enforcement bodies if required by law and others who provide
We may also disclose your personal information to other services to us or on our behalf, some of which may be located
companies within the Bupa Australia Group. We do everything outside of Australia.
reasonable to ensure your personal information is kept secure
from unauthorised access or disclosure. For more details on how we collect, store, use and disclose
your information, please read our Privacy Policy located
From time to time, we may contact you (via mail, email, phone or at www.ial.com.au/privacy-page. Alternatively, contact us at
SMS) to notify you about products, services or benefits offered [email protected] and we will send you a copy.
by Bupa, its related entities and affiliate organisations which we We recommend that you obtain a copy of this policy and read
consider of potential benefit to you and your family. If you do not it carefully.
wish to be contacted for marketing or promotional purposes, you
may opt out by contacting us. By applying for, using or renewing any of our products or
services, or providing us with your information, you agree to this
IAL’s Privacy Notice information being collected, held, used and disclosed as set out
We use your information to allow us to offer our products and in our Privacy Policy.
services. This means we may need to collect your personal
information, and sometimes sensitive information about you as Our Privacy Policy also contains information about how you
well (for example, health information for travel insurance). We will can access and seek correction of your information, complain
collect this information directly from you where possible, but there about a breach of the privacy law, and how we will deal with
may be occasions when we collect this information from someone your complaint.
else. IAL will only use your information for the purposes for which
it was collected, other related purposes and as permitted or
required by law. You may choose not to give us your information,
but this may affect our ability to provide you with insurance cover.

8 Declaration

Important information – to be completed by the patient

I confirm that the information I have given on this form is accurate and correct, to the best of my knowledge. I understand that in the event that terms
and conditions of my plan have not been met, my insurer, IAL, and Bupa Global reserve the right to recover any costs directly from me. I confirm that
the treatment I am claiming for are not and could not be covered by my Medicare benefits.
I confirm that I give explicit consent to process my personal information with respect to this claim. I also give consent to Bupa to obtain my personal and
medical information and that of my dependants (if any) from my previous insurer. I confirm that I have brought this declaration and Privacy Notice to
the attention of such dependants.
Patient’s signature (Parent or guardian if patient is under 16)

Print Name: Date: D D M M Y Y Y Y

If you have any queries regarding your claim, log onto our website www.bupaglobal.com/membersworld or contact
our customer services team on:

¡ Telephone: +44 (0) 1273 323 563 ¡ Fax: +44 (0) 1273 820 517  ¡ Email: [email protected]

Email is used for your convenience and speed, but we cannot always guarantee the security of this method of communication.
You need to be aware that some companies and countries do monitor email traffic. You need to take this into account when
choosing to use this method of communication.
 Claim checklist
Please review the following checklist and ensure that the information and supporting documents are provided, where applicable:

Clear, readable and unobscured documents (photocopied receipts should not obscure any details, clear handwriting, etc)

Symptoms and/or diagnosis

Prescription for pharmacy and optical claims

Final itemised invoice to include treatment dates, description and cost of each service provided (please note we cannot accept interim
or estimate invoices)

Complete payment instructions including payment currency

Proof of payment for member/group/company paid claims

Signature, name and date provided for Medical declaration (Section 8)

Please, note that we may need to request additional information to complete the assessment of your claim.

Members: You will be able to track the progress of your claim on our MembersWorld website (https://membersworld.bupaglobal.com)

Bupa international private medical insurance is underwritten in Australia by Insurance Australia Limited ABN 11 000 016 722 (IAL), AFSL number 227681. This product is distributed
in Australia by Bupa HI Pty Limited (ABN 81 000 057 590) which is an Authorised Representative of IAL. All policies and claims in relation to this product are administered
by Bupa Insurance Services Limited of the United Kingdom.
AUS-GENE-CLAF-EN-XXXX-2102-0028299
NOTES