2022multicare Claim Formen

Insured by Supported by
MultiCare International Health Plan

Claim Form
• You must fully complete sections 1, 2, 3 and 4.
• Your medical practitioner must fully complete sections 5, 6, and 7.
• B oth you and your medical practitioner must sign and date this form and it must be accompanied by original receipted and numbered invoices,
payment receipts and prescriptions or it may not be processed.
• You must provide your membership and Passport/ID number in order for us to process your claim.
If you have any questions regarding this form or any other aspects of your cover, please telephone on: +357 22 88 22 22
– ask for the Claims Management Department.
1. Subscriber’s and patient’s details

Name of subscriber Passport/ID number
Membership number from your card Group number (if applicable)
Name of patient
Subscriber’s date of birth Patient’s date of birth
2. To be completed by patient (or subscriber if patient is under 18 years of age)

1. If payment is to be made to someone other than the subscriber (eg. the patient’s guardian) please complete the following:
I authorise benefit to be paid directly to:
Address
Signature of subscriber Date
2. Payments will be made in Euros unless we agree otherwise in writing.

In which currency was the treatment originally billed?
Name and telephone number of patient’s family doctor
Account number Sort code
Name of account holder Bank
3. If treatment was received outside Cyprus, you must answer the following questions:
(a) Country where treatment took place
(b) The reason for the patient being abroad
(c) Dates of departure and return to Cyprus from to
4. Are you claiming cash benefit for in-patient treatment? Please tick ✓ Yes No
If yes, please enclose a copy of your admission and discharge forms from the hospital.
Universal Life 1
3. Other insurer’s details
Is the treatment accident-related? Please tick ✓ Yes No
Is it covered under another insurance policy? Please tick ✓ Yes No
If you have answered ‘Yes’ to either of these questions, please give the name of the insurance company involved
4. Patient’s Declaration and Consent (to be completed by Patient)

We would like to inform you that the personal data which you shall provide to us by completing this form, concerning you and any members of your
family who are covered by the MultiCare International Health Plan, are being collected by Universal Life in accordance with the purposes mentioned
in the Consent For Processing of Personal Data that you have given when you enrolled in the MultiCare International Health Plan. For more information
regarding the collection, processing and security of your personal data please see our Privacy Policy that is posted on the Company’s website (www.
universallife.com.cy), which may be amended from time to time.
Specifically, the collection of the aforementioned data under this form is done for the purposes of:
1. Deterring any illegal claim and/or fraud where the same person claims compensation twice from two different insurance companies.
2. Collecting evidence (verified and numbered invoices and prescriptions) for the purpose of processing the claim. Universal Life may not be in a
position to settle a claim if it lacks adequate information relating to the patient and does not have the patient’s signature.
3. Correct internal administration and operation of the Company as well as confirmation of the cover. Otherwise Universal Life may not be in a position
to settle a claim if it lacks knowledge as to who is the patient or as to where the treatment was administered.
4. Confirmation as to whether the illness, accident, hospitalization etc for which the claim is submitted by the patient is covered by the Multicare
International Health Plan.
To fulfil the above mentioned purposes, on some occasions it is essential to obtain an additional medical report from your doctor, in addition to the
information that your medical practitioner has completed in the Medical Section (Section 6) of the Claim Form. We will inform you if we need to ask
for an additional medical report.
Your doctor shall not send your report to us, until you have read it and consented to its contents. If you do not agree with its contents then you can
again refuse to have it sent to us. Nevertheless, we may not be in a position to deal with your claim without this report.
Where, apart from the above report, it is absolutely necessary for us to discuss further your illness and the details of your treatment with your doctor in
order to fulfil the above purposes, we shall not communicate with your doctor unless you give us your written consent for this. If you do not give us your
consent by virtue of this document, you have the right to give your consent by virtue of another document which will be sent to you by Universal Life.
Patient’s declaration and consent

I declare that I am the patient, parent or guardian of the patient (if the patient is under 18 years of age) (please cross out what is not applicable).
I wish to claim benefit and declare that all the particulars I have given are to the best of my knowledge, true and correct.
In order that my claim may be assessed and settled: Please tick ✔
For adult dependants:

I hereby authorize the Subscriber to submit on my behalf any claim forms and/or other related documents necessary for the purpose of
submitting a claim pursuant to the terms of the Insurance Policy.
I hereby explicitly consent to the processing of my personal data by Universal Life Insurance Company Ltd for the purposes of evaluating
the present Claim Form.
I hereby explicitly consent to the processing of my sensitive (special category) personal data by Universal Life Insurance Company Ltd for
the purposes of evaluating the present Claim Form.
I hereby explicitly consent to Universal Life Insurance Company Ltd notifying and/or sending correspondence to the Subscriber which may
include personal and/or sensitive (special category) personal data for the purposes of evaluating the present Claim Form.
For minor dependants:

Exercising the parental authority of the dependant member(s), who is under the age of 18, I hereby consent on behalf of the dependant
member to the processing of his/her sensitive personal data by Universal Life Insurance Public Company Ltd for the aforementioned purpose.
Exercising the parental authority of the dependant member(s), who is under the age of 18, I hereby consent on behalf of the dependant
member to the processing of his/her personal data by Universal Life Insurance Public Company Ltd for the aforementioned purpose.
Also please tick below:

I hereby consent to Universal Life processing the personal data which I have included in this form and in any medical reports that may be
submitted on my behalf to Universal Life with my consent.
I consent and authorise my doctor to discuss my illness and the details of my treatment with Universal Life.
I agree that one copy of this consent document will have the validity of an original.
In case you wish to withdraw your consent regarding the processing of personal data carried out in the context of the present Claim Form, please
contact our Customer Service Department at 22-220000. We note that in case of such withdrawal of consent, we are legally obliged to stop all
processing of personal data which takes place on the basis of your consent and for the purposes of examining this Claim Form, however this may
affect the evaluation of your Claim from Universal Life.
Signature – To be signed by the patient concerned (parent/guardian if under 18) Date
Universal Life 2
5. Direct Settlement by Universal Life
In-patient treatment must be pre-authorised by Universal Life (see your handbook for details). You must contact us on +357 22 88 22 22
or by fax on +357 22 88 22 66 at least 10 days before treatment to arrange this.
The claim form must be submitted within 90 days of the start date of the treatment along with all original and numbered receipts/
invoices – as per the policy membership agreement. Claims will not be considered if not submitted within 90 days of treatment being
received. The issue of this form does not imply any liability on the part of Universal Life. We recommend you photocopy the completed
form and any enclosures for your own records.
6. Medical Section (To be fully completed by patient’s Medical Practioner – all boxes must be completed in block capitals please.
We will require evidence of any diagnostic tests undertaken and we may require the results of those tests. We will ask you if we do.)
1. Please give details of the symptoms presented
2. Please give the date your Patient first became aware of any signs or symptoms of the Date
conditions being claimed for (day, month & year)
3. Please give the date on which your Patient first consulted any Medical Practitioner for Date
this condition
4. Please give a full history of the medical condition requiring treatment including full Dates
details of any previous investigation/treatment together with relevant dates
5. Have you referred the patient for any diagnostic procedures? If so please give details
6. Please give the exact diagnosis (after all diagnostics have been completed)
7. Please give details of any current and/or further treatment planned
8. Drugs/other items prescribed (Please list) Number of tablets/volume Period covered by

of liquid prescribed medication
7. Hospital or clinic information (To be completed by medical practitioner)

Hospital or Clinic name and address
9. Name of patient receiving treatment (Please print)
Admission/treatment date Surgery date (if any) Anticipated discharge date
8. Medical practitioner declaration

I declare that I am the patient’s medical practitioner, and that the particulars given are to the best of my knowledge true and correct
Name of Medical Practitioner (Please print) Practice stamp
Signature
Date
Universal Life 3
For Universal Life Only
Claim user
Supervisor
Medical advisor
Manager
Final decision
Comments on payment
Insured by Supported by
Universal Tower, Re-Insured by AXA PPP healthcare Limited.

85 Dhigenis Akritas Ave., Registered Office: 20 Gracechurch Street,
P.O. Box 21270, 1505 Nicosia London, EC3V 0BG, United Kingdom
Tel: 22 88 22 22, Telefax: 22 88 22 00 Registered in England No. 3148119.
CLEN/01.22
Internet Home Page:

http://www.universallife.com.cy
Universal Life 4

2022multicare Claim Formen

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Insured by Supported by

MultiCare International Health Plan

1. Subscriber’s and patient’s details

Membership number from your card Group number (if applicable)

Subscriber’s date of birth Patient’s date of birth

2. To be completed by patient (or subscriber if patient is under 18 years of age)

Signature of subscriber Date

2. Payments will be made in Euros unless we agree otherwise in writing.

Name and telephone number of patient’s family doctor

Account number Sort code

Name of account holder Bank

(b) The reason for the patient being abroad

(c) Dates of departure and return to Cyprus from to

Is it covered under another insurance policy? Please tick ✓ Yes No

4. Patient’s Declaration and Consent (to be completed by Patient)

Patient’s declaration and consent

For adult dependants:

For minor dependants:

Also please tick below:

Signature – To be signed by the patient concerned (parent/guardian if under 18) Date

7. Please give details of any current and/or further treatment planned

8. Drugs/other items prescribed (Please list) Number of tablets/volume Period covered by

7. Hospital or clinic information (To be completed by medical practitioner)

9. Name of patient receiving treatment (Please print)

Admission/treatment date Surgery date (if any) Anticipated discharge date

8. Medical practitioner declaration

Name of Medical Practitioner (Please print) Practice stamp

Universal Tower, Re-Insured by AXA PPP healthcare Limited.

Internet Home Page:

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2. Payments will be made in Euros unless we agree otherwise in writing.

(c) Dates of departure and return to Cyprus from to