Download Emergency Dental Claim Form

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.