Claim Form

1. Your Details ✍ USE BLACK PEN ONLY AND PRINT IN UPPERCASE

Membership number Title First names

Surname Date of birth

If you have changed address since your last contact with the fund, please cross this box X and complete the details in the
address section overleaf.

2. Hospital Service Details Please complete this section if any of the services were performed while you were an inpatient in hospital.
Name of hospital Nature of illness Date of admission Date of discharge

3. Statement by Member Do you intend to make a claim for payment of these services from another party or insurer regarding workers
compensation, motor vehicle accident, school injury, medical negligence or public liability? X YES X NO If yes, please give details.
Were you travelling to or from work? X YES X NO

4. Details of Claim
Your original account/receipts/Medicare statement of benefits must accompany this claim. These will not be returned to you.
Provider Patient
Patient’s first name Date of service
paid Y/N Code*
1.

2.

3.

4.

5.
Provider name Provider number Type of service – Please write the appropriate code in the box.

1. Chiropractic – 1
Physiotherapy – 2
Podiatry – 3
2. Acupuncture – 4
Naturopath – 5
3. Osteopathy – 6
For all other claim
4. types, please write
the name eg.
5. Dental, Optical etc.

* As shown on membership card

5. Agent’s Authority If you’re authorising another person to collect cash benefits, complete this section before your claim is lodged.
Agent’s signature Member’s signature
SIGN SIGN
HERE HERE

6. Declaration by Member I declare that the information on this form is true and correct. I authorise the fund to check any of these services
with the relevant provider and if any benefits have already been paid by previous health funds.
Member’s signature
SIGN
HERE DATE: / / *0101A*

Locked Bag 1006, Matraville NSW 2036 Phone: 134 ahm (134 246)
Fax: 1300 fax ahm (1300 329 246) Web: www.ahmg.com.au Email: info@ahmg.com.au
Making a claim… Completing the form
- don’t wait in a queue! Please make sure you Only complete this Please complete this
Claiming is easy with ahm — post, phone, HICAPS or web are all enter your section if the claim section if you are
convenient options for you. We can deposit your benefits into your membership details involves services claiming payment of
bank, building society or credit union account, or mail you a clearly in this section. rendered in a hospital. these services from
cheque (mail claims only). If your ancillary claim benefit is less another party or
than $400 our TeleClaim or online claiming services enable you to insurer regarding any
make your claim straight away. We deposit the benefits directly type of compensation.
into your account and you then mail us the necessary receipts.
General Guidelines
The original accounts/receipts must accompany all claim forms.
They should be fully itemised and state the name, address and
details of your provider.
All original documents are scanned and retained as images so Claim Form
originals cannot be returned.
1. Your Details ✍ USE BLACK PEN ONLY AND PRINT IN UPPERCASE
We don’t pay a benefit towards claims more than two years (24 Membership number Title First names

months old) or where providers perform services for themselves, Surname Date of birth

their dependants or partners, or business partners and dependants.

If you have changed address since your last contact with the fund, please cross this box X and complete the details in the

Optical
address section overleaf.

2. Hospital Service Details Please complete this section if any of the services were performed while you were an inpatient in hospital.
We pay benefits for sight correcting appliances only, so a copy of Name of hospital Nature of illness Date of admission Date of discharge

the prescription for the lens/frame must accompany the first

optical claim.

Y
3. Statement by Member Do you intend to make a claim for payment of these services from another party or insurer regarding workers

L
compensation, motor vehicle accident, school injury, medical negligence or public liability? X YES X NO If yes, please give details.
Medicare Gap Benefits

N
Were you travelling to or from work? X YES X NO

O
You’ll need to send us the original statement of benefit from
4. Details of Claim

E
Medicare to claim the Gap benefit.

L
Your original account/receipts/Medicare statement of benefits must accompany this claim. These will not be returned to you.
Provider Patient

P
Patient’s first name Date of service
NOTE: The “Gap” benefit is the difference between the schedule 1.
paid Y/N Code*

M
fee and Medicare’s benefit for services performed while you’re an 2.

A
inpatient in hospital. Benefits aren't payable for outpatient services

S
3.
or where the patient was classified as a Medicare patient. 4.

Pharmaceutical
5.
Provider name Provider number Type of service – Please write the appropriate code in the box.

We pay benefits for prescription only products which exceed the 1. Chiropractic
Physiotherapy
–
–
1
2
Podiatry – 3
PBS component. Make sure your receipts include the name of the 2. Acupuncture
Naturopath
–
–
4
5

drug and the prescription number. 3. Osteopathy –

For all other claim
6

4. types, please write

Orthodontics
the name eg.
5. Dental, Optical etc.

Before you can claim for orthodontics, you’ll need to send us the * As shown on membership card
treatment plan from the orthodontist. 5. Agent’s Authority
Agent’s signature
If you’re authorising another person to collect cash benefits, complete this section before your claim is lodged.
Member’s signature
SIGN SIGN
Privacy Statement HERE HERE

Personal information provided by you on this form will be used to 6. Declaration by Member I declare that the information on this form is true and correct. I authorise the fund to check any of these services
with the relevant provider and if any benefits have already been paid by previous health funds.
deliver the health insurance products and services you request. Member’s signature
SIGN
Failure to provide all of the required information may result in HERE DATE: / / *0101A*

delays or prevent us from completing your request. The Locked Bag 1006, Matraville NSW 2036 Phone: 134 ahm (134 246)
Fax: 1300 fax ahm (1300 329 246) Web: www.ahmg.com.au Email: info@ahmg.com.au
information we collect from you is confidential. We will only
disclose this information to third parties who are contracted to the
fund to provide services or health programs. These contracts
ensure that third parties keep your information secure and
confidential. You need to sign this If you’d like someone To avoid delays make
Declaration or we to collect your benefits sure the details
You are entitled to access any of your personal information and to
cannot process your (cash/cheque) on provided for the
make corrections if needed. You can do this in writing or over the
claim. your behalf, please Benefits Claim are
phone.
complete this section. correct.

Change of Address/Contact Details Only complete this section if your details have changed.
Street address

Suburb State Postcode

Phone number Mobile phone number

Email address

Australian Health Management Group Limited ABN 96 003 683 298. A Registered Health Benefits Organisation. AHM/04/0405 WEB