Get Treatment Guarantee Form (pdf Version) - Allianz Worldwide Care

The Treatment Guarantee Form is a critical document for securing coverage for your medical treatments through Allianz Worldwide Care. This guide offers step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to effectively fill out the Treatment Guarantee Form

1. Press the ‘Get Form’ button to access the Treatment Guarantee Form. You will obtain the form in a downloadable format suitable for editing.
2. Begin by completing the patient section. Clearly provide the policy number, select the appropriate title (e.g., Mr., Mrs., Ms., or Other), and enter the first name, surname, and date of birth.
3. Move on to the contact details section, identifying who should be contacted regarding the Treatment Guarantee's progress. Fill in the contact person's name, relationship to the patient, and their telephone and email contact information. You may include a second contact if desired.
4. Next, complete the patient signature section. The patient must sign and date the authorization, which allows their medical practitioner to release relevant health information to Allianz Worldwide Care.
5. The medical provider must fill out the medical certificate section. Specify the treatment category and provide relevant dates, details about hospital charges, estimated costs, and the attending physician's information.
6. For the diagnosis, include the ICD 9/ICD 10/DSM IV codes and a full description. If applicable, provide current medication details and planned procedure/treatment information.
7. After the medical provider completes the medical certificate, ensure that they sign and authenticate the document with their official stamp.
8. Complete the data protection section by ensuring all necessary signatures are in place, which grants consent for data usage and addresses retention of personal information.
9. Finally, review the entire form for completeness and accuracy. Save any changes you made to the document, and prepare to submit the fully completed Treatment Guarantee Form via email, fax, or by post as outlined in the instructions.

Begin filling out your Treatment Guarantee Form online today to streamline your healthcare coverage process.