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I authorise TUH to use my personal information in accordance with TUH s Privacy Policy. 2. I have the authority to supply personal information for the people listed on the claim form and receipts/accounts. 6. I have attached my original fully itemised receipts/accounts with this posted claim form To agree with the above please tick the box if submitting this form via email or sign if posting. Free post to TUH Reply Paid 265 Fortitude Valley QLD 4006 Email to onlineclaims tuh. com.au Date Queensland Teachers Union Health Fund Limited ABN 38 085 150 376 For membership changes please log onto Member Services Online via www. Claim Form Please attach original accounts and receipts or Medicare Benefit statements. Did you know you can now claim online for benefits up to 400 Member number or Date of birth Member surname Your payment I would like my claim payment to be paid Into my bank account details adjacent Name of account holder registered with TUH BSB - Account number By cheque Enclose your claims receipts and we will take care of the details The number of receipts I have enclosed with this form is Receipts or accounts should display Name and address of the provider organisation or clinic providing the service name of person who received the service the date of the service whether the account is paid and a description of the product or service provided sufficient to enable us to identify the item or item numbers. My address has changed I would like my contact details address to be updated on my TUH records Home / Postal address Email address Mobile number SMS me when my claim has been processed Acknowledgement and declarations Please note Claims must be made within 2 years of the date of service I would like to claim my out of pocket expenses through Active Health Bonus. Only available on eligible levels of cover for more information phone 1300 360 701 or visit our website Don t forget to enclose your receipts from your service provider s. I confirm the costs involved in this claim are not recoverable as part of workers compensation* If they are please claim through Work cover The costs involved in this claim are not covered via third party insurance or damages. Payments made in such cases are subject to refund on settlement of your damages claim For inpatient hospital services please provide Name of Hospital Admission DateDischarge Date 1. 3. I authorise any medical practitioner or provider to supply information to enable the claim to be assessed* 4. I certify that all information on this claim form is true and correct. 5. I have scanned and attached my fully itemised receipts/accounts with this electronically submitted claim form* NB You must retain your receipts for twelve 12 months after the claim has been paid. 6. I have attached my original fully itemised receipts/accounts with this posted claim form To agree with the above please tick the box if submitting this form via email or sign if posting. Free post to TUH Reply Paid 265 Fortitude Valley QLD 4006 Email to onlineclaims tuh. com*au Date Queensland Teachers Union Health Fund Limited ABN 38 085 150 376 For membership changes please log onto Member Services Online via www.

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