please staple original itemised accounts / receipts behind here
claim form
Policy holder details
Title (dr, mr, mrs, miss, ms) Other name/s Current home address State Daytime contact number Policy Number (must be provided) Postcode Email address Mobile please tick box if your address has changed Given name Date of birth Suburb / / Family name (surname)
Add dependants
1 Family name (surname) Date of birth 2 / /
Family policy holders only - complete details for your spouse and/or your dependants under 18 yrs Given / other name/s Gender M F
Family name (surname) Date of birth / /
Given / other name/s Gender M F
Details of expenses claimed
Patient's first name 1 2 3 4 5
Provider of service (e.g. Dr Jones)
Date of service (dd/mm/yy) (e.g. doctor visit or medicine purchase) / / / / / / / / / /
Have you already paid for this service? yes yes yes yes yes no no no no no
If accounts are unpaid, payments will be made directly to the provider. Please direct any enquiries from the provider direct to OSHC Worldcare
This section must be completed for all claims
Are these expenses related to an injury that occurred at work or as a result of a motor vehicle accident? At work Motor vehicle accident yes no Neither Are the expenses claimed for a medical assessment, x-ray or blood tests required for the renewal or issue of your visa?
Complete this section if you saw a doctor or went to hospital
Original tax invoices and receipts for paid expenses must be attached to process your claim Have you had this or a related condition before? yes no If yes, please provide details (dates, name & address of treating doctors/s, treatment etc)
How do you want to be paid?
(only complete if you have already paid the account and have attached original tax invoices and receipts) Cheque or Payment by EFT (electronic funds transfer) Name of account holder Account number (up to 9 digits)
Name of financial institution BSB number (6 digits)
Declaration
I declare that all statements and particulars contained on this claim form are true and correct. I authorise OSHC Worldcare to contact the hospital or provider of any service for further clarification of details in this claim if necessary. Signature Date
[email protected]
1800 651 349
office use only
Incident #
Protection of your personal information
The information that you provide is collected for the purpose of issuing you with OSHC Worldcare insurance and determining any claims you may make on this policy. The information may be disclosed to education providers, health fund providers, underwriters, marketing and service provider intermediaries, government departments, medical practitioners, claim accessors, investigators, medical assistance providers, associated companies, hospitals and other international assistance providers in the course of providing these services. When you applied for this insurance you agreed, in respect of any claim, to allow us to provide details of your cover or to obtain details from any healthcare provider in order to process your claim. OSHC Worldcare guarantees that the information will only be used for those purposes. If you would like to gain access to any of the information you have provided please contact OSHC Worldcare.
Did you know?
Direct Billing Medical Providers
OSHC Worldcare has an extensive network of medical providers around Australia - show your valid OSHC Worldcare card and you do not have to make a claim. The bill is sent directly to OSHC Worldcare (some medical providers may charge a small co-payment which can not be claimed). Find your local Direct Billing Medical Providers online at www.oshcworldcare.com.au.
Online Services www.oshcworldcare.com.au
Visit our website to: Submit online claims (be sure to send in you original receipts with your claim number) Renew your policy Order replacement membership cards View our helpful information video Read health and wellbeing information
24 Hour Emergency Helpline 1800 814 781
24 hour / 7 days per week access to medical, legal and interpreting services
Waiting Periods
The waiting period for a pre-existing condition is 12 months from the date you arrive in Australia, or if you are an on-shore applicant who previously did not hold a student visa, or the date your student visa was granted, whichever is the later date. During this 12 month period, you cannot claim for any costs associated with any ailment, illness, disability or condition or secondary condition related to this ailment, illness, disability or condition that you have suffered from at any time before you came to Australia, or before the date your student visa was granted, whichever is the later date.
Please return completed claim form together with all original receipts/invoices to:
OSHC Worldcare Locked Bag 3001 Toowong QLD 4066 Phone: 1800 651 349 Email: [email protected] Web: www.oshcworldcare.com.au
ETI Australia Pty Ltd ABN 52 097 227 177
