Get Please Return This Form To: 24 Upper Ground, London, Se1 9pd Tel: 020 7202 1381 Or: Suite 1

Filling out the claim form accurately is essential for timely processing of your request. This guide will provide you with a clear, step-by-step approach to complete the form online, ensuring that you submit all necessary details without any delays.

Follow the steps to accurately complete your claim form.

1. Press the ‘Get Form’ button to access the form and open it in the editing interface.
2. In section A, begin by entering your surname in the designated field, followed by your forenames. Fill in your address and postcode, ensuring accuracy for correspondence purposes. Provide a daytime telephone number and an email address where you can be reached.
3. Next, enter your registration number, then affix your signature in the appropriate box. Indicate the name of your employer if your contributions are being deducted from your pay or pension.
4. Provide the details of your bank or building society account, including the name of the account holder(s), sort code, and account number. Please note that this section must be completely filled out to avoid delays in processing your claim.
5. In section B, respond to the questions posed regarding your medical condition. Start with the diagnosis provided by a healthcare professional and describe your symptoms if no diagnosis was made. Record when symptoms began and when you first consulted a family doctor.
6. If applicable, indicate whether your current illness relates to any previous conditions. Specify the date of the previous illness if applicable.
7. Complete the patient details in section C, including surname, forenames, and date of birth. If you are completing this on behalf of a child under 18, indicate that clearly.
8. Sign the authorization for your hospital or hospice to release information concerning your admission and treatment dates.
9. In sections D and E, include details of the day case treatment and associated hospital information. Validate these with the hospital's official stamp and designated signature.
10. List any enclosed receipts and ensure they adhere to the stated requirements. Choose the appropriate claim category by checking the respective box.
11. Finally, review your form thoroughly, ensuring you have enclosed all necessary documents, signatures, and your bank account details. Save your changes to the document, download it for your records, and print a copy as needed.

Start filling out your claim form online today to ensure a smooth submission process.