Claim form

Important information
For quicker handling of your claim, simply log in to your MembersWorld account and either complete a digital version of this claim
form, or complete the mandatory fields as shown on the ‘submit a claim’ section. Alternatively, you can return this form with original
or copied invoices by post to: Bupa Global, Victory House, Trafalgar Place, Brighton, BN1 4FY, UK.

To prevent delay with the handling of your claim, please complete all sections of the claim form clearly. The form should be returned
to us within 2 years of the initial treatment date. Please write clearly in black ink and BLOCK CAPITALS.

Please complete a new / separate claim form for:

¡ each patient ¡ each in-patient / day-stay case ¡ each medical condition ¡ each reimbursement currency

We are unable to return original documents, but we will be happy to provide certified copies on request.

Before submitting the claim please refer to the checklist at the end of the form.

1 Patient’s details (to be completed by the person undergoing treatment)

Patient membership number: Group name (if applicable):

BI - - -

Title:

First name:

Family name:

Other names:

Date of birth: D D M M Y Y Y Y Age last birthday:

Current correspondence address:

Building:

Street:

Town / city:

Area code: PO Box:

Region:

Country:

Email:

Telephone (Please include country code, area code and number):

Please note, all future correspondence will be sent to this address. You can update your contact information at any time by visiting
MembersWorld (https://membersworld.bupaglobal.com).

If posting your claim to us, would you like an email acknowledgement to confirm receipt of your claim? Yes No

If yes to email, please write your email address clearly here

 (all sections must be completed by the Medical Practitioner in overall charge of the patient’s
2 Claim/medical details treatment where possible, otherwise it should be completed by member)

In which country did the treatment take place?

What is the currency of the invoice?

What is the total amount of the claim?

Medical Details:

Reason for treatment / visit to medical practitioner, such as your symptoms and diagnosis if known:

Is the treatment related to: Wellness/preventative Maternity Oncology Dental

Onset date when symptoms first noticed by patient: D D M M Y Y Y Y

When did the patient first see a doctor?: D D M M Y Y Y Y

Details of treatment received, including operations and medications:

Medical Practitioner’s details:

Name:

Speciality/Qualifications:

Address:

Email:

Telephone (Please include country code, area code and number):

Hospital admission details (if applicable):

Admission date: D D M M Y Y Y Y Discharge date: D D M M Y Y Y Y

Hospital name:

Address:

Email:

Telephone (Please include country code, area code and number):

Medical practitioner’s signature

Print Name: Date: D D M M Y Y Y Y

 3 Cash benefit

The hospital should complete this section if there were no charges for your overnight admission, and your plan includes a cash benefit

I confirm that
was in hospital from to
And this admission was free of charge

The hospital needs to stamp this claim form here:

4 Payment details

Important information
We can settle claims in over 80 currencies. This must be in one of the following; (i) the currency in which you pay your premium
(ii) the currency of the invoices you send us or (iii) the currency of your bank account.

Who would you like us to pay? (select one only)

Doctor Hospital/Clinic Patient/Member (enclose proof of payment) Group/Company (enclose proof of payment)

Please complete either Section A or Section B

Section A – Payment by Electronic Funds Transfer to a bank account

Bank name:

SWIFT / BIC code:*

Sort code (UK only): - -

Account number:

Full IBAN number:*

Account name / payee:

Currency for the transfer:

Bank address:

Post / Zip code:

Country:

*To process your payment as quickly and securely as possible, we strongly recommend this option as a preferred payment method.
Please provide both your IBAN and the SWIFT code of your bank branch. Your bank will be able to provide you with this information
if necessary.
We recommend that bank transfers are made in the currency of your bank account. If you submit a claim and have asked us to pay you,
your benefit will be paid less the amount of deductible or co-insurance applicable to your plan. If you have asked us to pay the provider,
and an annual deductible or co-insurance applies to your cover, the shortfall will be collected using your direct debit or credit card.
If you are part of a company plan, we will send payment to the medical provider for the eligible claim. We will deduct from this
payment the remaining annual deductible or co-insurance on your membership. You are responsible for paying any shortfall to the
provider after your claim has been assessed and paid. To find out if you have a co-insurance or deductible on your plan, please refer to
your membership certificate. To find out more about how co-insurances and deductibles work please refer to your membership guide.
Section B - Payment by cheque

In which currency would you like us to pay the cheque (please select one only)

Currency of your invoices Currency of your premiums Currency of your bank account

Other, please specify:

Cheques payable to members will be sent by post to the correspondence address provided on the front page
5 Third
5 YOURparty insurers
CONSENT TO OBTAIN A MEDICAL REPORT
Are some of the costs recoverable from someone else (for example, state insurer or a person / organisation involved in an accident?): Yes  No 

Name:

Address:

Email:

Telephone (Please include country code, area code and number):

6 Your consent to obtain a medical report

Important information
In order to process your claim, we may need to apply for a medical report from any doctor who has attended you. To apply, we need
you to give your consent by signing the declaration below.
Please read this section carefully, as it sets out your rights under the Access to Medical Reports Act 1988 and the Access
to Personal Files and Medical Reports (NI) Order 1991.
If you receive treatment in the UK, you can choose from three courses of action.
1. You can give your consent without asking to see the doctor’s report before it is sent to us. The report will then be sent directly
to us by the doctor.
2. You can give your consent, but ask to see any report before it is sent to us, in which case you will have 21 days, after we notify you
that we have requested a report from the doctor, to contact your doctor to make arrangements to see the report. If you fail
to contact the doctor within 21 days, they will be entitled to send the report direct to us. If however you contact your doctor with
a view to seeing the report, you must give the doctor written consent before they can release it to us. You may ask your doctor
to change the report if you think it is misleading. If your doctor refuses, you can insist on adding your own comment to the report
before it is sent to us.
Should you give your consent to us obtaining a report without indicating that you wish to see it, you can change your mind by
contacting your doctor before the report is sent to us, in which case you will have the opportunity to see the report and ask the
doctor to change the report or add your comments before it is sent to us, or withhold your consent for its release.
3. You can withhold your consent but, if you do, please bear in mind that we may be unable to accept your claim.
Whether or not you indicate that you wish to see the report before it is sent, you have the right to ask your doctor to let you see
a copy, provided that you ask them within six months of the report having been supplied to us.
Your doctor is entitled to withhold some or all of the information contained in the report if (a) they feel that it may be harmful
to you or (b) it would indicate their intentions in respect of you or (c) would reveal the identity of another person without their
consent (other than that provided by a health professional in their professional capacity in relation to your care). Your doctor may
also make a reasonable charge for their services.
The undersigned authorises and requests any hospital, specialist, physician or other health provider to furnish Bupa or its duly
authorised agent acting on Bupa’s behalf with such information as Bupa or that agent may seek from them in connection with any
treatment or other services provided to me or my dependant for the purpose of Bupa considering this claim.
If you are receiving treatment in the UK, by signing this form you are confirming that:
I have been advised of my rights under the Access to Medical Reports Act 1988 and the Access to Personal Files and Medical Reports
(NI) Order 1991.

If you receive treatment in the UK please indicate below if you wish to see a copy of the medical report before it is sent to Bupa:
I do wish to see a copy of any medical report before it is sent to Bupa.
I do NOT wish to see a copy of any medical report before it is sent to Bupa.
7 Privacy notice

We are committed to protecting your privacy when dealing with 5. Processing for Profiling and Automated Decision Making
your personal information. This privacy notice provides Like many businesses, we sometimes use automation
an overview of the information we collect about you and how to provide you with a quicker, better, more consistent and fair
we use and protect it. It also provides information about your service, as well as with marketing information we think will be
rights. The information we process about you, and our reasons of interest (including discounts on our products and services).
for processing it, depends on the products and services you use. This may involve evaluating information about you and, in
You can find more details in our full privacy notice available at: limited cases, using technology to provide you with automatic
www.bupaglobal.com/privacypolicy. If you do not have access responses or decisions. You can read more about this in our full
to the internet and would like a paper copy of the full privacy privacy notice. You have the right to object to direct marketing
notice, please contact the Bupa Global service team on and profiling relating to direct marketing. You may also have
+44 (0)1273 323 563. Alternatively you can email or write to the rights to object to other types of profiling and automated
team via [email protected] or Bupa Global, Victory House, decision-making.
Trafalgar Place, Brighton BN1 4FY, United Kingdom. If you have
any questions about how we handle your information, please 6. Sharing your information
contact us at [email protected]. We share your information within the Bupa Group, with relevant
policyholders (including your employer if you are covered
Information about Bupa Global under a group scheme), with funders who arrange services
In this privacy notice, references to “we” or “us” or “our” on your behalf, those acting on your behalf (for example
are to Bupa Global. For company contact details, visit brokers and other intermediaries) and with others who help
www.bupaglobal.com/legal-notices. us provide services to you (for example healthcare providers)
or who we need information from to handle or check claims
1. Scope of our privacy notice or entitlements (for example professional associations). We
This privacy notice applies to anyone who interacts with us in also share your information in accordance with the law. You
relation to our products and services (“you”, “your”), in any way can read more about what information may be shared in what
(for example email, website, telephone, app). circumstances in our full privacy notice.

2. Ways in which we obtain personal information 7. Transfers outside of the UK and the European Economic
We collect personal information from you and from certain third Area (EEA)
parties (for example those acting on your behalf, like brokers, We deal with many international organisations and use global
healthcare providers and so on). If you give us information about information systems. As a result, we transfer your personal
other people, you must make sure that they have seen information to countries outside of the UK and the EEA (the EU
a copy of this privacy notice and are comfortable with you giving member states and Norway, Liechtenstein and Iceland),
us their information. for the purposes set out in this privacy notice.

3. Categories of personal information 8. How long we keep your personal information

We process the following categories of personal information We keep your personal information in line with periods using
about you and, if it applies, your dependants. This is standard the criteria shown in the full privacy notice available
personal information (for example information we use on our website.
to contact you, identify you or manage our relationship with
you), special categories of information (for example health 9. Your rights
information, information about race, ethnic origin and religion You have rights to have access to your information and to ask
that allows us to tailor your care), and information about any us to correct, erase and restrict use of your information. You
criminal convictions and offences (we may get this information also have rights to object to your information being used,
when carrying out anti-fraud or anti-money-laundering checks to ask us to transfer information you have made available
or other background screening activity). to us, to withdraw your permission for us to use your
information and to ask us not to make automated decisions
4. Purposes and lawful grounds of our processing personal which produce legal effects concerning you or significantly
information affect you. Please contact us if you would like to exercise any
We process your personal information for the purposes set out of your rights.
in our full privacy notice, including to deal with our relationship
with you (including for claims and complaints handling), 10. Data Protection Contacts
for research and analysis, to monitor our expectations of If you have any questions, comments, complaints or
performance (including of health providers relevant to you) suggestions about this notice, or any other concerns about the
and to protect our rights, property, or safety or that of our way in which we process information about you, please contact
customers, or others. The legal reason we process personal us at [email protected]. You can also use this address
information depends on what category of personal information to contact our Data Protection Officer.
we process. We normally process standard personal information
on the basis that it is necessary so we can perform a contract, We are regulated by the Information Commissioner’s Office
for our or others’ legitimate interests or it is needed or allowed (www.ico.org.uk) who can be contacted at, Wycliffe House,
by applicable law. We process special categories of information Water Lane, Wilmslow, Cheshire SK9 5AF, United Kingdom.
because it is necessary for an insurance purpose, because we Tel: 0303 123 1113 (local rate) or 01625 545 745 (national rate).
have your permission or as described in our full privacy notice. You have a right to make a complaint to them or to your local
We may process information about your criminal convictions privacy supervisory authority.
and offences (if any) if this is necessary to prevent or detect
a crime.
 8 Declaration
Important information - to be completed by the patient
I confirm that the information I have given on this form is accurate, correct and complete, to the best of my knowledge. I give
explicit consent on behalf of myself or the patient (if acting on the patient’s behalf) for the doctors and any other medical
providers responsible for my treatment, care or other services provided to me, to provide Bupa Global or its service partners
with any information requested in connection with this claim or any past claim, for the purpose of considering, processing,
auditing or otherwise handling this claim.

Patient’s signature (Parent or guardian if patient is under 16)

Print Name: Date: D D M M Y Y Y Y

If you have any queries regarding your claim, log onto our website www.bupaglobal.com/membersworld or contact our customer
services team on:

¡ Telephone: +44 (0) 1273 323 563 ¡ Fax: +44 (0) 1273 820 517  ¡ Email: [email protected]

Email is used for your convenience and speed, but we cannot always guarantee the security of this method of communication.
You need to be aware that some companies and countries do monitor email traffic. You need to take this into account when
choosing to use this method of communication.
Please refer to your membership certificate for details of your insurer.

Claim checklist

Please review the following checklist and ensure that the information and supporting documents are provided, where applicable:

Clear, readable and unobscured documents (photocopied receipts should not obscure any details, clear handwriting, etc)

Symptoms and/or diagnosis

Prescription for pharmacy and optical claims

Final itemised invoice to include treatment dates, description and cost of each service provided (please note we cannot accept
interim or estimate invoices)

Complete payment instructions including payment currency

Proof of payment for member/group/company paid claims

Signature, name and date provided for Medical declaration (Section 8)

Please, note that we may need to request additional information to complete the assessment of your claim.

Members: You will be able to track the progress of your claim on our MembersWorld website (https://membersworld.bupaglobal.com)

Bupa Global is a trading name of Bupa Insurance Limited and Bupa Insurance Services Limited which are registered in England and Wales at Companies House under numbers
3956433 and 3829851 respectively. The registered offices are 1 Angel Court, London EC2R 7HJ, UK. Bupa Insurance Limited is authorised by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Bupa Insurance Services Limited is authorised and regulated by the
Financial Conduct Authority. The Financial Registration numbers of Bupa Insurance Limited and Bupa Insurance Services Limited are 203332 and 312526 respectively.

BIN-GENE-CLAF-EN-XXXX-2102-0027627
Notes