Get Axa Reimbursement Form

Filling out the Axa Reimbursement Form online is a straightforward process that requires careful attention to detail. This guide will provide clear, step-by-step instructions to help users complete the form efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in an editor.
2. In the 'Details of Member' section, provide your family name, first name, member card number, email address, and telephone number. Ensure all information entered is accurate.
3. Move to the 'Claim Information' section and fill in the details of the healthcare provider, including their name and address. Next, enter the service date, a description of the services provided, invoice number, and the total invoice amount. Specify the currency used.
4. Indicate the total amount as per the invoice. If the medical service was received outside the applicable network, select the reason from the provided options such as emergency, personal choice, or other, and provide additional details, if necessary.
5. In the 'Declaration' section, read the statement and provide your signature and date to confirm the accuracy of the information. This grants AXA the authority to obtain any necessary medical records.
6. Select your preferred payment method in the appropriate section, ensuring it aligns with the conditions of your policy. Specify the name of any other party if payment differs from the contract.
7. Fill out the section designated for medical information if applicable, which is to be completed by the treating doctor. This may include a diagnosis, visit date, treatment details, and a doctor’s signature along with their stamp.
8. Before finalizing, double-check that all sections are completed correctly and that the necessary supporting documents are attached, such as the itemized bill and prescription.
9. Finally, save your changes, and choose to download, print, or share the completed form as needed for submission.

Begin the process and complete your Axa Reimbursement Form online today.