nib276522_0418
Visit
austhealth.com or call 1800 22 11 33
1
IMAN Australian Health Plans Pty Ltd ABN 34 144 907 746
a subsidiary of nib holdings limited ABN 51 125 633 856
CLAIM FORM
Please credit my SafeClaim account (if you have authorised IMAN to credit your account using a Direct Credit Authority Form)
Please send me a cheque made out in my name
Please send me a cheque made out in my partner’s name (only available if you have authorised IMAN to do this)
If you have not yet paid the account, IMAN will send you a cheque to forward to your provider. You will need to pay the rest
of your bill.
Please note: Claim benefits are paid by nib health funds limited abn 83 000 124 381 (on behalf of IMAN Australian Health Plans Pty
Ltd ABN 34 144 907 746).
How do you want IMAN to pay your claim?
STEP 3
1. Is any part of your IMAN health premium either reimbursed or directly paid for by your Sponsor/Employer? Yes
No
If you answered Yes to question 1 above please skip question 2.
2. Do you have an Australian Business Number (ABN), and are you registered for Goods and Services Tax (GST)? Yes
No
Please answer the below questions
STEP 4
Your family name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Your first name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Your current postal address (this is the address we will send any correspondence to do with this claim)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
State. . . . . . . . . . . . . . . . . . . . Postcode. . . . . . . . . . . . . . . . . Daytime Phone number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Policy Number
Complete your policy details
STEP 1
I am claiming everyday Extras (e.g. General Dental, Optical, Physiotherapy, Prescriptions)
Date of
service
Type of service
Name of the provider
Patient name
Is this related to
compensation?
Is the account
paid in full?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Complete the details of your claim
STEP 2
I am claiming medical services (e.g. Hospital, Doctor and Specialist fees)
Date of
admission
Date of
discharge
Name of the provider
Is this related to
compensation?
Is this the result
of an accident?
Is this account
paid in full?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Do you have a Medicare card? Yes
No
If you answered Yes: Type of card (please tick) Permanent
Interim
Reciprocal
Card number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Start Date ____ /________ Expiry Date ____ /________
nib276522_0418
Visit
austhealth.com or call 1800 22 11 33
2
IMAN Australian Health Plans Pty Ltd ABN 34 144 907 746
a subsidiary of nib holdings limited ABN 51 125 633 856
TO SUBMIT YOUR FORM
Complete your form and submit in one of the following ways:
Mail
IMAN Australian Health Plans
Reply Paid 62208
Locked Bag 2010
Newcastle NSW 2300
If you have questions call the Customer Contact Centre:
Monday to Friday 8.30am – 6.00pm (AEDT)
Call 1800 22 11 33
From overseas +61 2 4914 1131
I have attached all the receipts and/or accounts for each item I am claiming.
All the receipts/accounts I have attached are original, itemised in full, written in English, and are on the provider’s official
stationery or have the provider’s official stamp.
I received the services within the last two years. (IMAN does not pay claims made two years or more after the services
were received)
I am claiming services from an IMAN recognised provider. (IMAN does not pay claims for the services of providers who are
not recognised by IMAN)
I have indicated where applicable that the claim is related to worker’s compensation.
CLAIMS CHECKLIST
Read the following important information and sign this form
STEP 5
Your Signature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date ____ /____ /________
(or your authorised partner)
By signing this form, I declare that all information I have provided to IMAN, including all information in this form, is true &
correct. I authorise IMAN to use this information and any other information I have previously given IMAN to assess and
process my claim(s). I consent to IMAN contacting my previous health fund and/or service provider to request information
and/or personal and medical records to verify any aspect of the claim(s). I acknowledge and provide consent for IMAN to
use this information for other purposes related to this claim as outlined in the IMAN Privacy Policy.
I confirm these services have not been claimed as Point of Service such as HICAPS and that this claim is not subject to
workers compensation, damages action, third party insurance or any other source.
I confirm that the services I am claiming were performed by the providers, and received by the persons as indicated on the
healthcare provider’s receipts.
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