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This guide will help you navigate the process of filling out the Out-patient Claim Form for Laya Healthcare effectively. By following these steps, you will ensure that your claim submission is accurate and complete.

Follow the steps to fill out the Out-patient Claim Form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your member’s details. Include your membership number, title, surname, date of birth, forenames, telephone, and correspondence address.
3. Provide details for dependants by entering their names and relationship to the main member.
4. Complete the MRI section. Enter the date of the MRI, reason for referral, MRI center, procedure names and codes, and the GP/consultant who referred you. Ensure you sign and date the section.
5. For any accidents, describe the accident/injury with the corresponding date. Indicate whether expenses are recoverable from another source and provide details as necessary.
6. If applicable, fill out the V.A.C therapy information, including date of admittance, description of injury, hospital name, and consultant's signature.
7. In the emergency dental section, provide details about the injury, work carried out, treatment dates, and dentist's signature and stamp.
8. Record receipt details, including treatment type, number of receipts, and total cost for each relevant treatment.
9. Input your payment details. Include the names of account holders, account number, bank sort code, and the bank's full name and address. Sign and date the payment section.
10. In the declaration and consent section, confirm the accuracy of your statements by signing. If the patient is under 16, a parent or guardian must sign.
11. Once all sections are filled out, save your changes, and choose to download, print, or share the form as needed.

Complete your documents online today to streamline your claim process!