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Article Structure

The AXA PPP International form serves as a crucial tool for individuals looking to file a health insurance claim. Designed to streamline the claims process, it consists of three main sections: Claim Details, Patient Consent, and Medical Details. In the first part, patients are required to provide essential information such as their personal details, membership number, contact information, and specifics about the treatment they are claiming. Clear instructions guide them on writing legibly, using black ink, and detailing the relevant treatment history. The second part focuses on obtaining patient consent, ensuring that AXA can collect necessary medical data from healthcare providers. This consent is pivotal for claims processing and serves as a means to establish trust and transparency. The final section is completed by the patient's healthcare practitioner, who documents critical medical information, including diagnoses, treatment dates, and any related medical conditions. By compiling comprehensive information through this form, AXA aims to facilitate a swift and efficient claims review process, enabling patients to focus on their health and recovery.

Axa Ppp International Example

Medical information form

Here to help

+44 (0) 1892 556274

Available day or night, 365 days a year

Please help us to review your claim quickly by writing clearly

There are three parts to this form:

Part

Who needs to complete this part

A:Claim Details the patient making the claim

B:Patient Consent the patient making the claim

C:Medical Details the patient’s Doctor or Medical Practitioner

Definitions of words and phrases

Please send your completed form to:

Upload or secure email via: axaglobalhealthcare.com/customer

Fax: +44 (0) 1892 508256

Post: AXA – Global Healthcare, Phillips House, Crescent Road, Tunbridge Wells, Kent, TN1 2PL, UK

Some of the words and phrases we use on this form have a specific meaning, for example when we talk about treatment.

You and your – when we use you and your, we mean the lead member and any family members covered by your policy.

We, us, and our – when we use we, us or our, we mean AXA Global Healthcare (UK) Limited acting on behalf of AXA PPP healthcare Limited.

Part A: Claim details – to be completed by the patient

A1 About you and your claim

Please remember to use BLACK INK and write in BLOCK CAPITALS throughout

Full name and title

Address

Please give full address details, including postal code and country where applicable.

Membership/customer number

Claim number (if known)

Contact details

Please include country and area codes, where applicable. Please give the Parent or Legal Guardian’s details if the patient is under 16.

Telephone

Email

Date of birth

D D M M Y Y Y Y

Reason for claim

Please describe the symptoms or medical condition being treated

Continued on next page

Page 1 of 7

PB63233/01.21

A2 Claim payment details

Have you already paid any bills for the treatment you’re claiming for?

No Please go to section A3

Yes Please complete the rest of this section

We’ll pay for any treatment you’re covered for directly into your bank account.

Please attach all itemised receipted invoices for the treatment as well as any medical certificates, correspondence or documents relevant to the claim.

To avoid any delays with your claim, please make sure you list:

The dates of the treatment

The type of treatment

 

The medical condition

The invoice value

 

 

 

 

 

Currency for claim to be paid in

 

IBAN (if relevant to your bank’s location)

 

 

 

 

 

 

 

 

 

 

 

Country

 

SWIFT or BIC code

 

 

 

 

 

 

 

 

 

 

 

Bank account number

 

ABA number (if relevant to your bank’s location)

 

 

 

 

 

 

 

 

 

 

 

Payee name

 

Bank name and address

 

 

 

 

 

 

 

 

 

 

 

Account name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have further treatment planned, please contact us on +44 (0) 1892 556274 or online by following the instructions at axaglobalhealthcare.com/customer

A3 Further information

Do you want to claim a cash benefit for treatment received free of charge?

No

Yes If yes, please send confirmation of the dates of your stay or treatment with this form and proof that the services were provided free of charge.

Is the treatment following an injury or accident? No Please go to Part B

Yes

a. Do you feel that someone else was at fault and caused the accident or injury?

No

Yes

b. Do you have another insurance policy that would also cover your claim?

No

Yes If yes, please give details

Other insurer details

PB63233/01.21

Page 2 of 7

Part B: Declaration and Consent

I declare that all the information I have given on this form is correct to the best of my knowledge. To support the administration of my health insurance arrangements I consent to:

a)AXA PPP healthcare Limited and/or AXA Global Healthcare (UK) Limited (jointly AXA) requesting medical and health information from the patient’s healthcare practitioner and/or hospital (please see the Medical Reports section of this form)

b)the healthcare practitioner and/or hospital providing that health information in reports, or by copies of my health records and medical information, to AXA

c)the healthcare practitioner and/or hospital involved in the patient’s care reviewing medical information and discharge arrangements with AXA for the following reasons: (Please tick yes or no for each of the following)

(a)to assess and subsequently review my claim and apply policy terms/exclusions (if you tick no we may not be able to process your claim)

Yes

No

(b)to audit healthcare practitioner and hospital records to review their performance and ensure that AXA is being billed correctly

Yes

No

I declare that I am the patient

Yes

No

Is the patient under 16 years of age?

No

Yes

If yes, I declare that I am the patient’s parent/guardian

No

Yes

I wish to see any report from the medical practitioner before it is sent to you

Signed*

(This form must be hand signed. We do not accept electronic signatures.)

*If the patient is under 16, this form must be signed by their parent/legal guardian

Date

D

D

M

M

Y

Y

Y

Y

Patient’s full name

No Yes

I wish for another person/other organisation(s) to help me with this claim and I agree, for that reason, that AXA or any policy administrator and the person/ organisation(s) named below may discuss this claim and to the extent necessary disclose to each other my relevant health and medical details.

No

Yes

If you answered yes please give the name of the person or organisation(s) here:

(if you give names of one or more organisation(s), this will mean that we can communicate with any employee [which will help if the person you usually deal with is not available]).

PB63233/01.21

Page 3 of 7

Part C: Medical information

To be completed by the patient’s medical practitioner – please help us by typing or writing clearly

Patient Name

Date of birth

D D M M Y Y Y Y

How long has this patient been known to you?

Are you the patient’s usual primary-care physician?

No

Yes

Do you have access to the patient’s medical history? No See below

Yes

If no, please tell us the name and address of the person who holds the patient’s medical history file

C1 Medical details

Medical condition / Diagnosis

ICD Code

 

Surgical Code (if appropriate)

 

 

 

 

 

 

Description of Symptoms

How long have symptoms existed prior to consulting you?

When did the symptoms first start?

D

D

M

M

Y

Y

Y

Y

If there are no symptoms, what prompted the patient to see you?

Given the aetiology of the condition, how long do you think the condition has been present?

Date of first treatment or consultation with any provider

D

D

M

M

Y

Y

Y

Y

Date of treatment with you

 

 

 

 

 

 

 

 

 

D

D

M

M

Y

Y

Y

Y

Type of investigation required to confirm diagnosis

Further treatment plan (if any)

Was the patient referred to you by another medical practitioner?

No

Yes If yes, please provide name and contact details of referring medical practitioner

Is the claim related to or as a result of any previous surgery or treatment?

No

Yes If yes, please detail, including dates

Continued on next page

PB63233/01.21

Page 4 of 7

C1 Medical details (continued)

Does the patient have any associated or related medical conditions?

No

Yes If yes, please state and explain the relation and date of diagnosis

Has the patient received any previous consultation(s)/ treatment or hospitalisation for this condition or for associated conditions or symptoms?

No

Yes If yes, please detail

Date of treatment

D D M M Y Y Y Y

Medical condition/treatment

Provider name

Is the patient taking any medication for this condition?

No

Yes If yes, name of drug and date of starting medication

If the claim relates to pregnancy, is the pregnancy a result of natural conception?

No

Yes

If the claim relates to pregnancy, is this the patient’s first pregnancy?

No If no, please detail any previous complications of pregnancy

Yes

PB63233/01.21

Page 5 of 7

C2 Medical practitioner declaration

I am the patient’s medical practitioner and confirm that the information I have provided is correct to the best of my knowledge. I understand that, if any of the information is incorrect, this may affect my patient’s claim for private healthcare expenses

Signature

Print name

Date

D

D

M

M

Y

Y

Y

Y

Email address

Contact telephone number

Practice Stamp

PB63233/01.21

Page 6 of 7

Medical Reports

If we ask for a medical report with details of your current condition, the history of your condition and any proposed treatment you don’t have to give your consent however if you don’t give consent we may not be able to process your claim.

If you wish to see the report before it is sent to us please tick the box below. We will write to you to tell you the date we request the report and you must contact the medical practitioner within 21 days of the date of our request. You have 21 days from the date of contacting your medical practitioner to arrange to see it.

I wish to see any report from the medical practitioner and/or hospital before it’s sent to AXA

If you don’t tick the box but then change your mind, you can contact your medical practitioner and ask to see the report.

You can ask the medical practitioner to see the report at any time within six months of the medical practitioner sending it to us.

If you disagree with the information in the report, you can ask the medical practitioner to change it. If the medical practitioner does not agree with you, they will ask you to write a statement to go with the report that is sent to us.

Your medical practitioner does not have to show you parts of the report if they think it could cause harm to your physical or mental health, or if it shows future plans for your care that the medical practitioner doesn’t want you to see.

If the report includes information about someone else, the medical practitioner will not show you that part of the report.

Your medical practitioner may charge you for a copy of the report. This charge is not covered by your plan.

If any medical records we receive show that a medical condition should have been declared on your plan application, we may change the terms of your plan.

Data Protection

We’ll handle your personal data in accordance with all relevant Data Protection legislation.

You are entitled to see information we hold about you. You can write to us to ask for a copy of any personal information about you in any independent reports we request. If you would like a copy of a medical report that your medical practitioner has sent to us, it will be quickest if you contact them direct because we will have to get their permission to release it to you.

PB63233/01.21

To ensure that we are able to provide the best service to you we process claims in various countries throughout the world.

We may audit the medical records of medical practitioners and hospitals to:

prevent and detect crime, particularly fraud,

review the performance of specialists,

ensure that we are being correctly billed for their services.

Audits may be part of a programme or in response to a specific event.

We may need to share information with third parties including medical experts, other insurers and other organisations concerned with the detection and prevention of fraud.

In certain circumstances we are required by law to disclose information to law enforcement agencies about suspicions of fraudulent claims and other crimes. This may involve adding non-medical information to databases that can be viewed by other insurers and law enforcement agencies. We may also be required to tell relevant regulatory bodies about any issue where we have reason to doubt a medical provider’s fitness to practise.

For our full Privacy Policy please see www.axaglobalhealthcare.com/privacynotice

Integrated healthcare for group health schemes

If you’re a member of a company healthcare scheme your employer may also provide or use our Occupational Health Service and/or Employee Assistance Programme. These services are provided by separate companies.

With your consent we and these companies will share sensitive and/or personal information, in confidence on an ethical need to know basis to provide you and your employer (in the case of Occupational Health Services and the Employee Assistance Programme), with support and advice about your health.

AXA Global Healthcare (UK) Limited is registered in England (No. 03039521). Registered Office: 20 Gracechurch Street, London EC3V 0BG United Kingdom. AXA Global Healthcare (UK) Limited is authorised and regulated in the UK by the Financial Conduct Authority.

We may record and/or monitor calls for quality assurance, training and as a record of our conversation.

Page 7 of 7

Form Characteristics

Fact Name Details
Purpose This form is used to submit claims for healthcare treatment covered by AXA PPP International policies.
Parts of the Form The form consists of three parts: Claim Details, Patient Consent, and Medical Details.
Submission Methods Completed forms can be submitted via upload, secure email, fax, or post.
Contact Information For assistance, customers can call +44 (0) 1892 556274, available 24/7.
Patient Consent The patient must consent to AXA requesting medical information from their healthcare provider.
Governing Law This form is governed by laws applicable in the UK.

Guidelines on Utilizing Axa Ppp International

Filling out the AXA PPP International form is essential for ensuring your claim is processed accurately. Make sure to allocate some time to complete each section carefully, as this will help expedite the review process.

  1. Gather Information: Collect all necessary details regarding your claim, including your membership number, claim number (if available), and invoices related to your treatment.
  2. Fill out Part A - Claim Details: Start with section A1. Use black ink and block capitals to fill in your name, address, date of birth, and contact details. Include information about the medical condition being claimed.
  3. Claim Payment Details: In section A2, specify if you have already paid any related bills. If yes, provide all requested banking details to facilitate direct payments.
  4. Provide Further Information: In section A3, indicate if the treatment followed an accident and whether someone else was at fault. Include details about other insurance coverage, if applicable.
  5. Complete Part B - Patient Consent: Carefully read the consent statements and check the appropriate boxes. Ensure your signature is included at the bottom along with the date.
  6. Fill out Part C - Medical Information: This section must be completed by your doctor. Make sure they provide details about your medical condition, treatment, history, and any other necessary information.
  7. Review: Before submitting, double-check all entries for accuracy and completeness. Verify that any required documents are attached.
  8. Submit the Form: Send the completed form and any supporting documents to AXA using your preferred method: upload online, secure email, fax, or postal mail.

Once the form is submitted, keep an eye on the communication from AXA for any updates or additional requirements. This will ensure that your claim is processed smoothly and efficiently.

What You Should Know About This Form

What is the purpose of the AXA PPP International form?

The AXA PPP International form is designed to streamline the claims process for medical treatments. It allows members to submit their claims efficiently, ensuring that necessary information is provided for prompt assessment. Completing it accurately can help avoid delays in receiving your benefits.

Who needs to complete each part of the form?

This form has three parts: - Part A (Claim Details) is to be filled out by the patient making the claim. - Part B (Patient Consent) is also completed by the patient. - Part C (Medical Details) must be filled out by the patient's doctor or medical practitioner. Each section has specific information that needs to be filled in to support the claim.

What information do I need to provide in Part A?

In Part A, you need to provide personal information such as your full name, address, contact details, date of birth, and details regarding your claim. Describe the symptoms or medical condition clearly and provide your membership number and claim number if available. Remember to use black ink and write in block capitals to ensure readability.

What should I do if I have already paid for treatment?

If you have already paid any bills related to the treatment, you need to complete all sections under claim payment details. This includes attaching itemized receipts and invoices, specifying the currency, and providing your bank account details for direct payment processing.

How can I ensure my claim is processed without delays?

To avoid delays in processing your claim, provide all required information accurately and completely. Attach any relevant documents like medical certificates and itemized invoices. Clearly state the dates, types of treatment, and medical conditions involved. Following these guidelines will help expedite your claim review.

Do I need consent from the patient to share medical information?

Yes. Patients must consent for AXA PPP healthcare to request medical information from their healthcare practitioners. This ensures that the necessary medical history and health information can be reviewed to assess the claim effectively. Consent is indicated in Part B of the form.

What is considered a medical condition for the claim?

A medical condition refers to any diagnosed health issue or symptoms that require treatment. You should describe the specific symptoms, the duration of their existence, and how they prompted the consultation. This information helps in accurately assessing what treatment is necessary under your policy.

What if the claim is related to an accident?

If your claim is based on an injury or accident, you will need to provide additional details in Part A. Specifically, you must indicate if someone else was at fault, and if you have other insurance coverage that could apply. This information is critical for determining liability and coordination of benefits.

How should I submit the completed form?

You can submit your completed AXA PPP International form in several ways. You can upload it or send it via secure email through axaglobalhealthcare.com/customer. Alternatively, fax it to +44 (0) 1892 508256 or mail it directly to the specified address in the UK. Ensure you keep a copy for your records.

Common mistakes

Completing the AXA PPP International form can sometimes lead to errors that may delay the claims process. One common mistake is not using the correct writing tools. The instructions specify using black ink and writing in block capitals. Using other colors or writing in cursive can result in illegibility, causing confusion and potentially stalling your claim.

Another frequent error involves providing incomplete or incorrect personal details. It's essential to offer your full name, address, and membership number accurately. Omitting any information or including errors can lead to delays or even rejections. Similarly, failure to include the patient’s contact details with the appropriate country and area codes may complicate communication.

People often overlook the importance of attaching all relevant documents as stated in the form. This includes itemized invoices and medical certificates. Inadequate documentation can lead to processing delays. Documenting additional information such as dates of treatment or the medical condition being treated is crucial for a smooth claims process.

Another pitfall is neglecting to check the cash benefit options. If you are claiming for treatment received without charge, confirming this detail is necessary. Be sure to provide evidence along with the claim form. Failing to do so can lead to complications in processing your request.

Errors can also arise in understanding the consent section of the form. Visitors must ensure that they consent to AXA requesting necessary medical information accurately. Misunderstanding this section, or failing to provide clear consent, may hinder the claims processing.

When it comes to the declaration section, it's crucial that the patient or their legal guardian signs the form. The absence of a proper signature can make the entire submission invalid. Keep in mind that electronic signatures are not accepted, which can be a potential drawback if overlooked.

A significant mistake can occur when answering questions related to previous medical conditions. Being vague or leaving these questions blank could result in complications later on, especially if additional insurance is involved. All previous treatments or conditions should be listed thoroughly to avoid any discrepancies.

Finally, a lack of communication with the medical practitioner can be detrimental. Ensuring that they fill out their section clearly and comprehensively is vital. Complicated medical histories or lack of clarity in diagnoses can lead to confusion. Always encourage your healthcare provider to provide detailed and precise information to ensure a smoother claims process.

Documents used along the form

In addition to the AXA PPP International form, several other documents are often required to ensure a comprehensive and effective claims process. Completing these forms accurately can speed up approvals and help you get the coverage you're entitled to. Here is a brief overview of these additional documents.

  • Medical Report Form: This form is completed by the patient's doctor and details the medical condition, treatment history, and any relevant diagnoses. It plays a crucial role in substantiating claims and ensuring accurate assessments.
  • Claim Submission Letter: A formal letter that accompanies your claim submission. This letter outlines the details of the claim, including the reasons for the claim and any corresponding documentation attached. It provides essential context for the claims processor.
  • Itemized Bills: These detailed invoices list all charges associated with the treatment received. Each charge corresponds to a specific service or procedure, helping to clarify the financial aspects of the claim.
  • Consent to Release Medical Information: Often required by insurers, this document gives permission for healthcare providers to share your medical history and treatment details with the insurance company. It is important for maintaining privacy while facilitating the claims process.
  • Proof of Payment: This may include receipts or bank statements showing that payment was made for medical services rendered. Such proof is vital in verifying that expenses claimed were indeed incurred by the patient.
  • Accident Report Form: If the claim is due to an accident, this document may need to be filled out. It typically includes details about the incident, witnesses, and any party at fault, which can impact the claims decision.
  • Additional Insurance Information: If the patient has more than one insurance policy, this document provides details about the other policy holders and their coverage, which can affect how claims are processed.

Completing these forms alongside the AXA PPP International form helps establish a clear and thorough record for your claim. This not only facilitates a smoother claims process but also helps ensure that all deserved benefits are paid out accurately and promptly.

Similar forms

  • Health Insurance Claim Form: This document is similar as it also collects detailed patient information and the nature of the claim. Both forms require personal identification, specifics of treatment, and confirmation of consent for information sharing.

  • Medical Records Release Authorization: Like the AXA PPP International form, this document involves obtaining permission from the patient to share medical details with a third party for the purposes of processing a claim. It ensures confidentiality and compliance with privacy regulations.

  • Patient Information Questionnaire: This document is designed to gather comprehensive medical history and current health status. Similar to the AXA form, it aims to provide a healthcare provider with essential background information necessary for efficient claim handling.

  • Invoice Submission Form: This form complements the AXA PPP International form by allowing patients to submit itemized invoices for treatments received. Both documents require clear details about the services rendered to ensure accurate claim processing.

Dos and Don'ts

When filling out the Axa Ppp International form, here are five important things to keep in mind:

  • Use Black Ink and Block Capitals: Always fill out the form clearly in black ink and use block capitals to avoid any confusion.
  • Provide Complete Information: Ensure you include full details such as your full name, full address, and all relevant contact information. Missing details can lead to delays.
  • Attach Required Documents: Don’t forget to include itemized invoices, medical certificates, and any other documents that support your claim.
  • Sign the Form: Make sure the form is hand-signed. Electronic signatures cannot be accepted.
  • Double-Check for Errors: After completing the form, review all information to catch any mistakes or omissions before submission.

Equally important, here are five things you should avoid doing:

  • Don’t Use Pencil: Filling out the form in pencil can lead to smudging and unreadability, which may slow down processing.
  • Avoid Abbreviations: Use full words instead of abbreviations to ensure clarity. Abbreviations can often be misinterpreted.
  • Don’t Skip Sections: Every part of the form is important. Make sure to fill out all sections that apply to your situation.
  • Never Leave Contact Information Blank: Without contact details, the claim may not be processed efficiently, or they may be unable to reach you if there are questions.
  • Do Not Ignore Consent Requirements: If the patient is under 16, a parent or guardian must complete and sign the form. Ignoring this can invalidate the claim.

Misconceptions

  • Misconception 1: All parts of the form can be completed by anyone.
  • The Axa PPP International form requires specific sections to be filled out by designated individuals. Part A is for the patient, Part B is for patient consent, and Part C must be completed by the patient’s doctor or medical practitioner.

  • Misconception 2: You can submit the form without proper signatures.
  • It's essential that the form is hand-signed by the patient or their legal guardian, especially if the patient is under 16 years old. Electronic signatures are not accepted.

  • Misconception 3: You can submit claims without providing medical details.
  • Medical details are necessary for claims processing. The form includes sections specifically for capturing medical conditions, diagnoses, and related information from the healthcare provider.

  • Misconception 4: All claims are paid directly to the patient.
  • The payment method depends on how the treatment was billed. If the patient has already paid for treatment, they must provide itemized invoices for reimbursement directly into their bank account.

  • Misconception 5: It’s acceptable to use any color ink on the form.
  • The instructions specify that you must use black ink and block capitals for all entries. This ensures that the information is clearly readable.

  • Misconception 6: Additional insurance coverage is irrelevant to the claim.
  • If you have another insurance policy that covers the same claim, details must be provided in the form. This information could impact the processing of your claim.

  • Misconception 7: There’s no need to list details of the treatment.
  • For smooth processing, it’s crucial to include a detailed description of the treatment. This should cover dates, types of treatment, conditions, and invoice amounts.

Key takeaways

When filling out the AXA PPP International form, keep these key points in mind:

  • Clear Writing: Always use black ink and write in capital letters to ensure legibility.
  • Complete Sections: The form has three parts, and all sections must be filled out accurately by the right individuals.
  • Include Contact Details: Provide comprehensive contact information, including address and phone numbers, to avoid communication issues.
  • Attach Necessary Documents: Include all receipts, invoices, and medical documents relevant to your claim to prevent delays.
  • Correct Authorization: Both the patient and their doctor must consent to share medical information. Ensure all signatures are provided as required.
  • Bank Account Information: If a direct payment is expected, ensure bank details are accurate to facilitate timely transactions.
  • Follow Up: If further treatment is planned, communicate with AXA promptly using the provided contact information.