Get Axa Reimbursement Form

Completing the Axa reimbursement form online is essential for efficient processing of your claim. This guide will provide you with step-by-step instructions to accurately fill out each section of the form to ensure a smooth reimbursement process.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the administrative section, fill in your membership number, patient date of birth, policy/group number, date of treatment, group/company name, gender, and patient name. Ensure all fields are completed as they are compulsory.
3. For the medical section, describe the symptoms presented, including the date the patient first became aware of the condition and any necessary investigations requested to define the diagnosis.
4. In the treatment advised section, provide details about drugs, procedures, the date on which the patient first visited a doctor for this condition, and any investigation and medical condition/diagnosis information.
5. In the further treatment planned section, outline any additional treatments that are planned for the patient.
6. Complete the other insurer's details section by answering whether the treatment was accident-related and if it is covered under another insurance policy. Provide the name of the involved insurance company if applicable.
7. Review the patient’s declaration and ensure all information is correct. The patient or their guardian must sign, date, and provide a declaration of the information's accuracy.
8. The medical practitioner must complete their section by providing their name, signature, stamp, and date.
9. In the administrative specific to reimbursement claims section, enter the amount claimed, the cheque beneficiary name, and the currency of the treatment billed.
10. Fill in the medical providers' details with the name, telephone number, and address of the medical provider.
11. If claiming for treatment received outside your area of cover, answer the specific questions regarding the country, reason for being abroad, and dates of departure and return.
12. Complete the payment details for bank transfer, including the bank account number, bank name, address, beneficiary name, and bank sort/swift code.
13. After all sections are filled out, save your changes, download, print, or share the form as needed to complete your submission.

Complete your Axa reimbursement form online today to ensure timely processing of your claim.