Overseas Visitors
Health CoverClaim form
Please complete both sides of this application in CAPITAL letters. Post or fax the application to Allianz Global Assistance OVHC with all
required attachments.

Policy holder details

please tick if your address has changed

Policy number (must be provided):
Type of policy:
Title:

Budget Visitors

DrMrMrs(Please attach a copy of your valid eligible visa)
Visitors Plus
Miss

Single plan

Dual family plan

Multi family plan

Family name (surname):

Ms

Given name:

Other name/s:

Date of birth: _ _ /_ _ /_ _ _ _Gender:

MFAddress:
Postcode:
Daytime contact number:

Mobile:Email address:
Passport number:

Nationality:

Details of expenses claimed
Date of service(dd/mm/yyyy)(e.g. doctor visit ormedicine purchase)Amount ofinvoice1.

__/__ /____

$

yes

no

2.

__/__ /____

$

yes

no

3.

__/__ /____

$

yes

no

4.

__/__ /____

$

yes

no

5.

__/__ /____

$

yes

no

Patient‘s first name

Provider of service(e.g. Dr Jones)

Provider number

Have you alreadypaid for thisservice?

• If accounts are unpaid, payments will be made directly to the provider. Please direct any enquiries from the provider to Allianz Global Assistance.
• If accounts are paid, original tax invoices and receipts must be attached to process your claim.
• If you hold a family policy (including dual family and multi-family policies) and are submitting a claim for a dependant covered by that policy, youmust ensure your dependant‘s details are registered on your policy. You can do this in the ‘Members’ section of the website or call our Members
Services on 1300 727 193.

This section must be completed for all claims
Are the expenses related to one of the following?

Work accident

Motor vehicle accident

Not an accident

Other type of accident (please specify)
Are the expenses claimed for a medical assessment, x-ray or blood tests required for the renewal or issue of your eligible visa?

yesnoPlease Note: You are required to provide a copy of your current eligible visa when making a claim.
Total amount of all claims lodged in this instance: $PLEASE TURN OVER AND COMPLETE PAGE 2 OF THIS FORM.
1Claim form

Complete this section if you saw a doctor
or went to hospital
Have you had this or a related condition before?

Did you know?
Direct Billing Medical Providers
yesnoIf yes, please provide details (dates, name & address of treating
doctors/s, treatment etc):

Allianz Global Assistance has an extensive network of medical providers around
Australia – show your valid membership card and you do not have to makea claim. The bill is sent directly to Allianz Global Assistance (some medicalproviders may charge a co-payment which cannot be claimed). Find your local
Direct Billing Medical Providers online at www.ovhcallianzassistance.com.au.

Cash Claims
Our cash claims service is available on-campus at most major Institutions.
See your local Client Service Representative to process claims under $105 andprovide you with vouchers redeemable for cash at Australia Post outlets. Checkour website for details of times and locations of Client Service Representatives.

Online Services – www.ovhcallianzassistance.com.au
Visit our website to:

Payment to Australian bank account by EFT(Electronic Funds Transfer)
Please provide correct bank account details to ensure prompt payment(only complete if you have already paid the account and have attachedoriginal tax invoices and receipts). If correct bank details are notprovided, a cheque will be sent to your Australian postal address.
Name of financial institution:
Name of account holder:• Submit online claims (be sure to send in your original receipts with yourclaim number)• Renew your policy• Order replacement membership cards• View our helpful information video• Read health and wellbeing information

24 Hour Emergency Helpline – 1800 814 781Emergency access to medical, legal and interpreting services

Waiting Periods

BSB number (6 digits):

Under both Basic Visitors and Visitors Plus, the waiting period in relation toa pre-existing condition (other than a psychiatric pre-existing condition) is
12 months.

Account number (up to 9 digits):

In addition, there is a waiting period of two months for psychiatric pre-existing
conditions and of 12 months for pregnancy related conditions.

Declaration
I declare that all statements and particulars contained on this claim
form are true and correct.
I authorise Allianz Global Assistance to contact the hospital orprovider of any service for further clarification of details relating tothis claim if necessary.

All waiting periods commence from the later of the following:(i) the date you (or your Dependant) (as the case may be) arrived inAustralia; or(ii) the date your eligible visa was granted.
You cannot claim for costs arising during the relevant waiting period if suchcosts arise from a pre-existing condition, psychiatric condition or pregnancy
related condition as applicable. See your policy document for further details in
relation to waiting periods.

Signature:

Protection of your personal information

Date: _ _ /_ _ /_ _ _ _We collect your personal information

Office use only
Incident #:Allianz Global Assistance will endeavour to process your claim within
10 working days of receiving a completed claim form and all original
documents.

Please return completed form to:
Allianz Global Assistance
Locked Bag 3004, Toowong QLD 4066
Phone: 1300 727 193
Fax:+61 7 3305 7316
Email:OVHCClaims@allianz-assistance.com.au

To arrange, manage, and provide your OSHC or OVHC health cover, we (AGAAssistance Australia Pty Ltd trading as Allianz Global Assistance as agent
for the insurer, Lysaght Peoplecare Limited) collect, use, and disclose yourpersonal information including sensitive information. We collect it fromyou as well as others including (but not limited to) your family members,
travelling companions, universities, other educational institutions, Government
Departments including those responsible for administering visa requirementsfor overseas visitors and students, doctors, hospitals, medical providers andothers we consider necessary. We disclose your personal information to variouspersons and entities including those mentioned above as well as to others
that assist us to provide our services and to carry out our normal business
functions and processes including to claims investigators and for legal recovery
purposes. For example, we collect, use, and disclose your name, address, dateof birth, medical and other sensitive information for these purposes.
We also use and disclose it so as to comply with regulatory requirements.
When you make a claim under your policy, you agree and consent to us
collecting, using and disclosing your personal information (including sensitiveinformation) as set out above including to your healthcare provider.
For more information about our handling of your personal information,
including details about access, correction and complaints, please contact
our Privacy Officer on (07) 3305 7000 or refer to our corporate privacy policy
available on request or on the web at www.allianz-assistance.com.au.
OVHC 0913

Allianz Global Assistance Overseas Visitors Health Cover is managed by AGA Assistance Australia Pty Ltd ABN 52 097 227 177. Lysaght Peoplecare Limited ABN 95 087 648 753,
a private health insurer under the Private Health Insurance Act 2007 (Cth) is the underwriter of Allianz Global Assistance Overseas Visitors Health Cover policies.

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