please staple original itemised accounts / receipts behind hereclaim form
Policy holder details
Title (dr, mr, mrs, miss, ms)

please tick box if your address has changed

Family name (surname)

Given name

Other name/s		

Date of birth

Current home address		

SuburbState

Postcode

Daytime contact number		//Email address
MobilePolicy Number (must be provided)

Add dependants Family policy holders only - complete details for your spouse and/or your dependants under 18 yrs
1

Family name (surname)Date of birth2/

Given / other name/s/GenderFamily name (surname)Date of birth/MF

Given / other name/s/GenderMF

Details of expenses claimed
Provider of service(e.g. Dr Jones)

Patient's first nameDate of service (dd/mm/yy)(e.g. doctor visit or medicine purchase)

Have you alreadypaid for this service?

1/

/

yes

no2/

/

yes

no3/

/

yes

no4/

/

yes

no5/

/

yes

noIf accounts are unpaid, payments will be made directly to the provider. Please direct any enquiries from the provider direct to OSHC Worldcare

This section must be completed for all claims
Are these expenses related to an injury that occurred at work or as a result of a motor vehicle accident?

At work

Are the expenses claimed for a medical assessment, x-ray or blood tests required for the renewal or issue of your visa?

Motor vehicle accident
yes

noComplete this section if you saw a doctor or went to hospital
Original tax invoices and receipts for paid expenses must be attached to process your claim
Have you had this or a related condition before?
yesnoIf yes, please provide details (dates, name & address of treating doctors/s, treatment etc)

How do you want to be paid?
(only complete if you have already paid the account and have attached original tax invoices and receipts)
Cheque orPayment by EFT (electronic funds transfer)

Name of financial institution		

Name of account holder

BSB number (6 digits)		

Account number (up to 9 digits)

Declaration
I declare that all statements and particulars contained on this claim form are true and correct.
I authorise OSHC Worldcare to contact the hospital or provider of any service for further clarification of details in this claim if necessary.
Signature			oshcclaims@worldcare.com.au1800 651 349

Date

office use only

Incident #NeitherProtection of your personal information
The information that you provide is collected for the purpose of issuing you with OSHC Worldcare insurance anddetermining any claims you may make on this policy. The information may be disclosed to education providers, health fundproviders, underwriters, marketing and service provider intermediaries, government departments, medical practitioners,
claim accessors, investigators, medical assistance providers, associated companies, hospitals and other international
assistance providers in the course of providing these services. When you applied for this insurance you agreed, in respectof any claim, to allow us to provide details of your cover or to obtain details from any healthcare provider in order toprocess your claim.
OSHC Worldcare guarantees that the information will only be used for those purposes. If you would like to gain access toany of the information you have provided please contact OSHC Worldcare.

Did you know?
Direct Billing Medical Providers
OSHC Worldcare has an extensive network of medical providers around Australia - show your valid OSHC Worldcare cardand you do not have to make a claim. The bill is sent directly to OSHC Worldcare (some medical providers may charge asmall co-payment which can not be claimed).
Find your local Direct Billing Medical Providers online at www.oshcworldcare.com.au.

Online Services – www.oshcworldcare.com.au
Visit our website to:• Submit online claims (be sure to send in you original receipts with your claim number)• Renew your policy• Order replacement membership cards• View our helpful information video• Read health and wellbeing information

24 Hour Emergency Helpline – 1800 814 781• 24 hour / 7 days per week access to medical, legal and interpreting services

Waiting Periods
The waiting period for a pre-existing condition is 12 months from the date you arrive in Australia, or if you are an on-shore
applicant who previously did not hold a student visa, or the date your student visa was granted, whichever is the later date.
During this 12 month period, you cannot claim for any costs associated with any ailment, illness, disability or condition orsecondary condition related to this ailment, illness, disability or condition that you have suffered from at any time before youcame to Australia, or before the date your student visa was granted, whichever is the later date.

Please return completed claim form together
with all original receipts/invoices to:
OSHC Worldcare
Locked Bag 3001 Toowong QLD 4066
Phone: 1800 651 349
Email: oshcclaims@worldcare.com.au
Web: www.oshcworldcare.com.au
ETI Australia Pty Ltd ABN 52 097 227 177