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CUSTOMER DETAILS Full name CUA Health policy number Address Phone/Mobile Is this your permanent address Yes Postcode No Please complete the following questions i Is this claim the result of an accident iii Are you entitled to treatment under repatriation social services or any other benefit in respect to this claim ii Is there an entitlement to claim for workers compensation or third party insurance damage CLAIM DETAILS Date of service Patient s name Have you attached the receipts Provider s name Account paid YES/NO Please ensure where applicable receipts are attached. Where an unpaid account is supplied the cheque will be made payable to the provider. CUA HEALTH LIMITED ABN 98 098 685 459 Reply Paid 100 Brisbane QLD 4001 P 1300 499 260 F 1300 797 066 E cuahealth cua*com*au Wwww. cuahealth. com*au Claim form Use this form to Make a claim for payment get a reimbursement or to add a family member to your policy. Unless requested all other refunds will be paid to your account. Failure to provide correct documentation could delay settlement of your claim* ADDING A NEW BORN CHILD Family name 2nd initial Sex First given name Date of birth DECLARATION I declare that the services claimed were received and that the above answers and particulars are true. I authorise practitioners named above to supply any information which will assist in processing this claim* I agree that my personal information will be collected used and disclosed in accordance with the privacy notice set out in the brochure and the CUA Group s privacy policy. Signed by member Date Once you have completed this form Please fax request to 1300 797 066 We re here to help CH04140304 Drop it into a branch Email cuahealth cua*com*au If you need assistance completing this form call us on 1300 499 260 or drop into your local branch. CUA HEALTH LIMITED ABN 98 098 685 459 Reply Paid 100 Brisbane QLD 4001 P 1300 499 260 F 1300 797 066 E cuahealth cua*com*au Wwww. cuahealth. com*au Claim form Use this form to Make a claim for payment get a reimbursement or to add a family member to your policy. Unless requested all other refunds will be paid to your account. Failure to provide correct documentation could delay settlement of your claim* ADDING A NEW BORN CHILD Family name 2nd initial Sex First given name Date of birth DECLARATION I declare that the services claimed were received and that the above answers and particulars are true. I authorise practitioners named above to supply any information which will assist in processing this claim* I agree that my personal information will be collected used and disclosed in accordance with the privacy notice set out in the brochure and the CUA Group s privacy policy. I authorise practitioners named above to supply any information which will assist in processing this claim* I agree that my personal information will be collected used and disclosed in accordance with the privacy notice set out in the brochure and the CUA Group s privacy policy. Signed by member Date Once you have completed this form Please fax request to 1300 797 066 We re here to help CH04140304 Drop it into a branch Email cuahealth cua*com*au If you need assistance completing this form call us on 1300 499 260 or drop into your local branch..

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