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Emergency Dental Claim Form Note: The tendering of this form does not constitute a guarantee of payment of benefit. Please have the dentist/dental specialist complete the Dentist Verification details section. Eligibility Criteria: Emergency Dental Services were required as a result of experiencing a trauma to the mouth as diagnosed and confirmed by a dentist/dental specialist. Reasonable steps must have been taken to prevent the trauma from occurring. The trauma must be a result of an accident leading to injury caused solely and directly by violent, external and visible means (this does not include self-inflicted events). The member must be examined by a Dentist or Dental Specialist within 48 hours of the accident. The trauma to the mouth must of occurred in Australia. Claiming options: - By email to [email protected] - By fax to (02) 6352 3408 - By Post to Westfund Home Office PO BOX 235, LITHGOW NSW Member Please attach all unaltered accounts/receipts with completed form. In the case of photocopies, faxes and emailed accounts/receipts, original documents must be retained by you, the member, for a minimum of 24 months from the date the claim is made. Westfund may request to sight the original document during this time. Claim must be made within two years of date of service to be eligible for a benefit. Phone: 1300 937 838 Membership Number: _____________________________________________________________ Member’s Full Name: ________________________________________________________________________________________________ First/Middle/Surname Member’s Home Phone: ( ) ____________________________________________ Patient’s Full Name: _______________________________________________________________________________________________________________ First/Middle/Surname Patient’s Date of Birth: _______/_______/_______ Day Month Patient’s Relationship to Member: __________________________ Year Patient Patient’s Home Address: ___________________________________________________________________________________ P/Code: _______________ Patient’s Home Phone: ( ) ____________________________________________________ Mobile: ___________________________________________ Name of Treating Dentist: ___________________________________________________________ Phone: ( ) ___________________________________ Address: _________________________________________________________________________________________ P/Code: ______________________ Were all reasonable steps taken to prevent the trauma occurring? Yes No Was the trauma caused solely and directly by violent, external and visible means? Yes No Date of Accident: _______/_______/_______ Accident Day Month Year Location of Accident: ____________________________________________________________________ Describe circumstances of Accident: _______________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ Describe Injury: ___________________________________________________________________________________________________________________ Was the Accident related to Workers Compensation or Third Party Insurance? Yes No Profession: ________________________________________________________________________________________________________________________ (Dentist, Dental Specialist etc.) Name: _____________________________________________________________________ Provider No: ________________________________________ Dentist Verification Patient’s Full Name: _______________________________________________________________________________________________________________ Patient’s Date of Birth: _______/_______/_______ Day Month Year Date of Accident: _______/_______/_______ Day Month Year Injury diagnosed: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ When did the patient first receive attention for the above? Date: _______/_______/_______ Day Month Year I certify that the emergency dental services recieved were required as a result of the patient experiencing a trauma to the mouth as diagnosed and confirmed by myself. Yes No Signature: _______________________________________________________________________________ Date: ______/______/______ Day W238 Month Year Authority for Payment Would you like your refund deposited directly into your bank account? Yes No EFT Details Name of Financial Institution: __________________________________________________________________________________________ Account Name: ______________________________________________________________________________________________________ Account Number: BSB Email Address: ____________________________________________________________________________________________________________________ Declaration I declare that this claim is for treatment or services received by myself and/or dependants. All details and answers in this form and all attached documents are true and correct. I authorise my medical practitioner, or health service provider, to provide Westfund with any details of medical treatment, hospitalisation, injury, disease, ailment or diagnosis about me or my dependants necessary to assess my entitlements. I have read and understood Westfund’s Privacy policy as referenced. a) Is this claim the result of an accident? ___________________________________________ Yes No b) Are you eligible to recover any costs/damages from any other source? e.g Third Party, Workers Comp, etc. ____________________________________________ Yes No c) Were you a hospital in-patient? _________________________________________________ Yes No If YES, period of hospitalisation from: _______/_______/_______ to _______/_______/_______ Name of Hospital: ............................................................................................................................................................................................................... Signature of Member: .......................................................................................................................................................................................................... Date: _______/_______/_______ OFFICE USE ONLY Day Is receipt attached? Note on membership? Date: ______/______/______ Yes Yes No Month Year Verified by: Benefit Paid: Payee: Claim Number: Westfund Ltd collects and uses your personal information such as your name, address, telephone and other contact details in order to answer your query or to provide our services to you. Westfund also collects sensitive information about you, such as your health information, in order to provide quotations for membership, to establish and maintain your policy and to provide health services to you. Unless it is unreasonable or impractical to do so, Westfund will collect your personal information from you. If you provide Westfund with the personal information of another person (such as about your family member), then you should make them aware of the matters contained in this notice. Not collecting your personal information the settlement of your claims. Westfund may disclose your personal information to other entities. However, your personal information will only be disclosed to third parties where you would reasonably expect Westfund to in order to provide you with the services associated with your membership. This may include parties transacting business on behalf of Westfund and supporting Westfund’s systems and services. Your personal information, including health information, may also be used if you access health services through Westfund’s health, dental and optical divisions or to notify you of new products or promotions. Your personal information will not be disclosed to any overseas recipients. Westfund’s Privacy Policy contains information about how you may access and seek correction of your personal information held by Westfund, and how you may make a complaint in relation to information privacy. Westfund’s Privacy Policy is available at our website www.westfund.com.au and at any of Westfund’s Care Centres. Further details can be obtained by contacting Westfund’s Privacy . Westfund Home Office 5 Railway Parade, Lithgow NSW 2790. PO Box 235, Lithgow NSW 2790. Phone: 1300 937 838 Westfund Limited ABN 55 002 080 864. Trading as Westfund. A registered private health insurer, under the Private Health Insurance Act. A not for profit health fund.