Cl
aim form
1 Your details
Member number Title
Firstname(s)
Surname Date of birth
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 Date of admission
Nature of illness 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 worker's compensation,
motor vehicle accident, school injury, medical negligence, public liability or any other form of compensation?
NO YES If YES, please give details:
Were you travelling to or from work?
NO YES
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
code*
paid Y/N Patient’s full name
Date of service
1
2
3
4
* This is the number shown next to the patient's name on the member card
Provider name Provider number
Type of service
1
2
3
4
Note: For certain claims, like sight correcting appliances, Medicare Gap, pharmaceutical, orthodontics, travel and accommodation we may need more
information than is on your receipt. Please check the Member Guide or contact us for what you need.
5 Declaration by member
I declare that the information on this form is true and correct. I authorise ahm to check any of these services with the relevant
provider and if any benefits have already been paid. I acknowledge that ahm health insurance may use the information on this claim form to assess and process this
claim, or for other purposes related to this claim as outlined in the ahm Privacy Policy. I confirm the services submitted on this claim form were performed by the
providers, and received by the persons named on this form. I declare these services cannot be claimed from any other source unless specified in question 3 above
.
Member’s signature
Date:
*0101F*
*0101F*
Submitting your claim
Log in to your account at ahm.com.au, go to the Upload documents section and upload this form under the
Claim form option.
You can also post to ahm health insurance Locked Bag 4, Wetherill Park NSW 2164
Your privacy: We’re subject to the Privacy Act 1988 and comply with the principles for handling your personal information. View the ahm Privacy
Policy at ahm.com.au or contact us to have a copy posted or emailed to you. ahm health insurance is a business of Medibank Private Ltd ABN 47
080 890 259. ‘ahm health insurance’ and ‘ahm’ are references to Medibank Private Ltd trading as ahm health insurance.
18241019
