Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it within your chosen editor.
2. In the 'Patient Details' section, enter the required information including your policy number, first name, surname, date of birth, correspondence address, telephone number, and email address.
3. Move to the 'Medical Details' section. Indicate the type of condition (Acute, Chronic, or Acute episode of chronic) and provide a detailed description of the symptoms or medical condition, including the ICD9/10 code or DSM-IV if applicable.
4. Provide the dates related to the patient's first presentation of symptoms and the onset of symptoms. Answer whether the patient has suffered from this condition previously, and include any treatment provided for related illnesses.
5. Indicate if the condition is likely to re-occur, if it requires rehabilitation, if it is permanent, and if it necessitates long-term monitoring or examinations.
6. If applicable, enter the Guarantee of Payment (GOP) reference number related to this treatment.
7. For cases related to pregnancy, fill in the estimated date of delivery and whether a single baby is expected. Provide any necessary details if multiple births are expected.
8. For claims related to physiotherapy or psychotherapy, complete the referral details by including the referring physician's name and contact information, as well as the date of referral.
9. Once all the information is filled out, the medical provider must sign and date the form, and include an official stamp if necessary.
10. The patient must also sign and date the declaration section, certifying that the information provided is accurate to the best of their knowledge.
11. Finally, ensure that all original receipts, invoices, and prescriptions are attached. Save your completed claim form, then download, print, or share it as needed.

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