Group Risk Claims Preliminary Medical Attendant s Statement

Transcription

1 Group Risk Claims Preliminary Medical Attendant s Statement 1 March 2013 OnePath MasterFund ABN RSE R SFN OnePath Custodians Pty Limited ABN AFSL RSE L Kent Street, Sydney NSW 2000 ANZ Smart Choice Customer Services Phone ANZSmartChoice@anz.com Postal address Please return completed forms to: ANZ Smart Choice Customer Services, Reply Paid 85728, Sydney NSW Please note If there is a fee for completion of this form it is the responsibility of your patient. To assist with a quick determination of this claim it is essential that a treating doctor completes this form. Please include copies of any investigation reports (including blood tests, x-ray and radiology reports) or treating specialist reports that support the diagnosis. Please ensure all sections of this form are completed, as this information will be relied upon when considering your patient s claim. If you are unable to complete any section please indicate your reasons for this. If there is insufficient space on this form, please use the space at the back of the form or attach a separate page. Please ensure that you identify the question for which the additional information relates to. Patient s full name Patient s address (number and street) Suburb/Town State Postcode Date of birth Height Weight 1. Diagnosis Primary Secondary 2. Please state the objective findings which support the above diagnosis. Please attach copies of investigation reports and treating specialist reports. 3. Please list current symptoms and severity of condition. 4. Are the symptoms consistent with the diagnosed condition?... Yes No 5. Is the severity of condition consistent with the pathology?... Yes No 6. Are you the patient s regular doctor?... Yes No If no, who is? Please provide details. 7. Did you know the patient personally before they consulted you professionally? Yes No 1 of 24

2 8. On what date did the patient first attend you for any reason?... / / 9. When did the patient first become aware of the claimed condition?... / / 10. When did this patient first consult you for the above condition?... / / 11. When was the condition first diagnosed?... / / 12. List all dates of consultation since. 13. What are the predisposing causal factors associated with the patient s condition? 14. So far as you are aware, how did the injury/illness arise? Please also provide the history your patient gave you at first consultation for the illness/injury. 15. Has the patient had the same or similar condition in the past?... Yes No If yes, please provide details. 16. Please describe the treatment prescribed, including all medication and dosages, and the response to this treatment. 17. Please outline any proposed treatment to assist the patient s recovery and return to the workforce. 18. Has the patient been compliant with treatment?... Yes No 19. What evidence do you have that they are compliant? If non-compliant, please state reason why. 20. Have all treatment options been attempted?... Yes No 21. Has the condition stabilised?... Yes No 22. Prognosis: Short term Long term 2 of 24

3 23. Please complete the table below with the relevant details for all referrals to other doctors. Doctor s name and speciality Date first consulted Date last consulted Surgery address Phone no. Referred by Reason for referral 24. Has the patient ever been hospitalised for this condition?... Yes No If yes, please provide details below. Please also enclose a copy of the hospital discharge summary. Name and address of hospital Date of admission Date of discharge 25. From what date was the patient first certified by a medical practitioner to be totally unfit for work?... / / If you did not certify the patient please advise the medical practitioner's details. 26. From what date was the patient fit to return to the workforce?... / / 27. Has the patient performed any work since that date?... Yes No If yes, please provide details. 28. Is this patient still totally unable to work in their pre-disability/usual occupation?... Yes No 29. When do you anticipate the patient will be fit for full duties?... / / 30. When do you anticipate the patient will be fit for partial/suitable/alternative duties?... / / 31. What are your patient s occupational duties? 32. Please list the specific occupational duties the patient is able to perform. 33. Do you recommend the appointment of a rehabilitation specialist to assist the patient in returning to the workforce?... Yes No If yes, please outline your recommendations below. If no, please state your reasons for this below. 34. Please list the specific duties the patient is unable to perform and the reasons why they are prevented from performing these duties. 35. Please quantify the number of hours the patient is able to work per week Please state any specific restrictions due to the subject medical condition (i.e. exclude pre-existing restrictions). Lifting below the waist kgs Sitting mins Kneeling mins Lifting at the waist kgs Walking mins Crawling min/mtr Lifting above shoulder kgs Standing mins Bending mins Carrying kgs Driving mins Climbing Reaching above shoulders kgs Working at heights Yes No Climbing Yes No min/mtr 3 of 24

4 37. Are there any other restrictions (excluding pre-existing restrictions)? 38. If the patient s employment was a significant or contributing factor to the symptoms, please provide details. 39. Is the patient suffering from any other condition or are there any other factors which might in any way contribute, aggravate or impair their ability to return to work?... Yes No If yes, please provide details. 40. Have you, or are you, completing forms or reports for any other organisation (e.g. insurance company, credit provider, Workers Compensation, Centrelink) or for sick leave?... Yes No If yes, please provide details. 41. Are you aware of the patient s full employment and educational history?... Yes No 42. Do you believe the patient will ever return to gainful employment?... Yes No 43. Please provide any additional information you believe would be beneficial to us when considering your patient s claim. Please attach the following to this completed form. Please tick the box to confirm document is attached. Any specialist and other medical reports. Hospital discharge summary if appropriate (for hospital stays of more than three days). X-ray and other radiology reports, pathology and other test results. List of all consultations or copies of clinical notes since first consultation. Any other information that will assist with the assessment of this claim. 4 of 24

5 Please note Due to court rulings, we may be required to provide this, or any other report you provide, to the Trustee, your patient, independent specialist and relevant industry body. Declaration I declare that the above details are true and correct. Your name Qualifications Surgery address (number and street) Suburb/Town Phone Fax Signature Date 5 of 24

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7 Group Risk Claims Preliminary Member s Statement 1 March 2013 OnePath MasterFund ABN RSE R SFN OnePath Custodians Pty Limited ABN AFSL RSE L Kent Street, Sydney NSW 2000 ANZ Smart Choice Customer Services Phone ANZSmartChoice@anz.com Postal address Please return completed forms to: ANZ Smart Choice Customer Services, Reply Paid 85728, Sydney NSW Please note This form must be completed in full to enable processing of your claim. If there is insufficient space on this form, please use the space at the back of the form or attach a separate page. Please ensure that you identify the question for which the additional information relates to. This is a claim for (please tick the correct box)... GSC or TPD Name of plan Policy number Name of employer Title Mr Mrs Ms Miss Dr Other Surname First name Maiden name (if applicable) Date of birth Male Female Height (cm) Weight (kg) Residential address Suburb/Town State Postcode Phone Home Work Mobile Country of birth Are you a permanent resident of Australia? Yes No How long have you lived in Australia? Years Months Language spoken at home Name of employer at date of disability Employer location/address Date last actively at work Gross annual salary immediately prior to ceasing work $,. Hours worked/week (e.g. a 38 or 40 hour week) Were you employed on a permanent or casual basis? Permanent Casual Occupation 7 of 24

8 1. Please list the duties of your occupation and % of time spent performing each. Please attach a full copy of your resume. Duty % of time Duty % of time 2. Cause of disablement and/or reason for ceasing work. Injury Illness Redundancy Resignation Termination Please provide details. 3. If an accident, please provide details including how, where and when the accident occurred. Please include the name and contact numbers of any witness and also attach any relevant police/incident reports etc. 4. If an illness, have you had this or a similar condition previously?... Yes No If yes, please provide a brief history. 5. List all the sports, hobbies and activities that you were involved in prior to your disability. 6. When did you first consult a doctor for this condition?... / / 8 of 24

9 7. Please complete the table below with the relevant details of your treating doctors and specialists. Doctor s name and speciality Date first consulted Date last consulted Surgery address Phone no. Referred by Reason for referral 8. If you have been hospitalised as a result of this disability, please provide details. If you were hospitalised for more than three days, please also enclose a copy of the discharge summary. Name and address of hospital Date admitted Date discharged 9. Please provide details of treatment to date and the results of this treatment (e.g. physiotherapy, medication or surgery etc). 10. Please advise of any proposed treatment together with anticipated dates of commencement. 9 of 24

10 11. Please complete the following table with full details of any payments you are receiving, are entitled to receive, or are pursuing since the date you last worked. This includes, but is not limited to, any income from other employment, Social Security/Centrelink, Workers Compensation/Common Law/CTP or other forms of insurance, annual leave, termination pay or any other source of payments. Please attach an itemised list of all payments received. Source of payments e.g. insurer name and claim no. Date claim commenced Date payments commenced Contact person Address Phone no. Gross weekly amount received 12. Dates of continuous total disablement due to this current medical condition (i.e. not working in any capacity):...from / / To / / 13. If you are currently disabled, please confirm when you anticipate returning to:...part-time duties / / Full-time duties / / 14. If you have already returned to work on a part time or restricted basis, please provide details of: a. date of return to part-time work... / / b. number of hours/week you are currently working If you have returned to work on a full-time basis, please provide date of return to work... / / 16. If applicable, please advise the duties you are currently unable to perform. 17. If a rehabilitation assessment/return to work plan has commenced, please complete the following. Rehabilitation provider Contact person Address Phone no. Date rehabilitation commenced Has a return to work plan been completed/ commenced? / / / / 10 of 24

11 18. If you have not been referred to a rehabilitation provider, are you interested in rehabilitation assistance (i.e. assistance with returning to the workforce)?... Yes No If yes, please provide details. 19. Employment history Please put the most recent job at the top and work down to the first job from leaving school. Period of employment Employer Job title Main tasks Reason for leaving 20. Please state in your own words how this disability is affecting you and/or make any further comments in relation to this claim. 11 of 24

12 Please attach the following with your completed form. Please tick the box to confirm the attachments. Certified copy of your current driver s licence or passport Hospital discharge summary if appropriate (for hospital stays of more than three days) X-ray and other radiology reports, pathology and other test results Resume Copies of claim payment letters from other sources Any other information that will assist with your claim. Please ensure this form is fully completed. Failure to do so may result in the form being returned and a delay in assessing your claim. Please note You may be required to attend an independent medical examination prior to a determination of your claim. Declaration and authority: I hereby declare that I am the person referred to in the above and that the answers are complete and true in every particular. I authorise: Any person, hospital or doctor with whom I have consulted, or any employer, to supply OnePath Life (or it s authorised representative) any information that it may require in the assessment of this claim. Any insurer, Centrelink and any other income, pension, annuity and disability support provider to provide OnePath Life with any information or reports that it requires for the assessment of the claim. OnePath Life to provide any information or document in respect of this claim to the Administrator of the Plan of which I am a member. OnePath Life to provide any information or document to any medical or rehabilitation provider that OnePath Life deems necessary to assist in the assessment of my disability OnePath Life (or its authorised representative), where my insurance is linked to my superannuation fund, to disclose my health information to the trustee of my superannuation fund (or their appointed administrator) to enable them to comply with their legal obligations. I agree that a photostat copy of this declaration and authority shall be considered as valid as the original. I understand that if I do not agree to this, OnePath Life will not be able to further assess my claim. Name (please print) Signature Date 12 of 24

13 Privacy Statement In this section we, us and our refers to OnePath Life and other members of the ANZ Group. We are committed to ensuring the confidentiality, security and privacy of your personal information. You and your refers to policy owners and life insureds. We collect your personal information to provide you with the products and services you request. Without your personal information, we may not be able to process your application or provide you with the products or services you require. In order to manage and administer the products and services requested by you, we may need to disclose your personal information to certain third parties, including: other members within the ANZ Group, to the extent necessary to service our relationship with you and carry on business as a group organisations performing administration or compliance functions in relation to the products and services organisations maintaining our information technology systems authorised financial institutions organisations providing services such as mailing, printing or data verification a person who acts on your behalf (such as your financial adviser or your agent) the policy owner (where you are a life insured who is not the policy owner). For life risk products we collect health information with your consent. Your health information will only be disclosed to service providers, reinsurers or organisations providing medical or other services for the purpose of underwriting, assessing the application or assessing any claim. We may also disclose your personal information in circumstances where we are required to do so by law. We may send you information about our financial products and services from time to time. You may elect not to receive such information at any time by contacting Customer Services on You may access the personal information OnePath holds about you, subject to permitted exceptions and subject to OnePath still holding that information, by contacting OnePath at: Privacy Officer OnePath GPO Box 75 Sydney NSW 2001 Phone Fax privacy@onepath.com.au If any of your personal information is incorrect or has changed, please let OnePath know by contacting Customer Services. More information can be found in OnePath s Privacy Policy which can be obtained from its website at onepath.com.au Privacy declaration: Please complete the following to indicate your consent: I acknowledge that I have read and understood the Privacy Statement. I accept and consent to the collection, use and disclosure of my personal information necessary for the purpose of administration and rollover of this claim/policy. I understand that OnePath will not be able to process my claim or administer this policy without this consent. Signature Date 13 of 24

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15 Total and Permanent Disablement Claim Employer s Statement 1 March 2013 OnePath MasterFund ABN RSE R SFN OnePath Custodians Pty Limited ABN AFSL RSE L Kent Street, Sydney NSW 2000 ANZ Smart Choice Customer Services Phone ANZSmartChoice@anz.com Postal address Please return completed forms to: ANZ Smart Choice Customer Services, Reply Paid 85728, Sydney NSW Please note Print in black or blue ink. Please attach a separate page if you require more space for an answer. Please ensure questions are answered in full where possible. Incomplete and unanswered questions may result in the claim being delayed and could result in this form being returned to you for completion. Name of Superannuation Fund / Employer Policy Number 1. Member details Surname Date of birth Given name(s) 2. Employer Business name Street no. and name Member number ABN Suburb/Town State Postcode Phone number Fax number 2.1 Did the Employee work at this address? Yes No If no, where did the Employee work? 3. Reason for ceasing work 3.1 What is the reason for ceasing work? Illness Injury Redundancy Resignation Termination 3.2 Please provide details: 15 of 24

16 Employment What was the Employee s usual occupation? Job title When did your Employee s employment start?... When was the Employee last actively at work?... Who was the Employee s direct manager? Name Title Phone 4.4 What was the basis of employment? Casual Part Time permanent Full Time permanent Contractor Annual salary (gross before tax) $,, Usual hours per week (weekly average over 12 months immediately prior to your injury/illness) 4.5 What were the main duties of the Employee s occupation? 4.6 Was the Employee working or employed in a supervisory capacity?... Yes No If yes, please provide details 4.7 Please indicate the physical demands of the Employee s occupation: Never Sometimes Often Always Never Sometimes Often Always Never Sometimes Often Always Walking Climbing Carrying above 23kg Sitting Driving Reaching (over shoulder) Standing Lifting less than 9kg Reaching Key: (below shoulder) Sometimes equals 1/3 of time or less Working with computers Lifting 9kg to 23kg Often equals between 1/3 to 2/3 of time Kneeling Carrying less than 9kg Always equals more than 2/3 of time Bending Carrying 9kg to 23kg 4.8 Has the Employee held any other positions with your business?... Yes No If yes, what other positions were held over what period? Position / Job title From To 16 of 24

17 Work activities Was the Employee on restricted duties on the first day of active work?... Yes No If yes, what duties was the Employee performing on the first day of work? 5.2 Did the Employee reduce their hours / duties as a result of the claimed condition prior to ceasing work?... Yes No If yes, please provide details 5.3 Has the Employee returned to work?... Yes No If yes, when and in what capacity? Date Duties 5.4 Hours Do you expect the Employee to return to work in any capacity?... Yes No If yes, please provide details 6. Training and development 6.1 Please detail all internal and external training provided to the Employee during their employment, including on-the-job training. Additional Details / Comments Declaration I declare that the information contained in this form is true, complete and correct. I understand that I can be prosecuted if I make any fraudulent statement. Name Position Signature (sign clearly within the box) Date 17 of 24

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19 Certificate of Medical Attendant 1 March 2013 OnePath MasterFund ABN RSE R SFN OnePath Custodians Pty Limited ABN AFSL RSE L (Trustee) 347 Kent Street, Sydney NSW 2000 ANZ Smart Choice Customer Services Phone ANZSmartChoice@anz.com Postal address Please return completed forms to: ANZ Smart Choice Customer Services, Reply Paid 85728, Sydney NSW Please note Please ensure that every question is answered. Incomplete forms will be returned. Patient details Surname Given names(s) Date of birth 1. Please state the diagnosis. If applicable indicate the severity of the condition. 2. Please list the member s most recent occupation. 3. Please list the member s past occupations. 4. Please list the member s training, education and experience. 5. In your opinion, is the patient ever likely to resume duties in any occupation for which they are reasonably qualified by their past education, training or experience?... Yes No 6. Terminal Illness Claims: Is the patient suffering from an illness which in the normal course would result in death within a period of 12 months?... Yes No Please note Any charge for this certificate must be paid for by the patient. I acknowledge my patient s authorisation for me to furnish the fund trustee any information that may be required in the consideration of this patient s application for an early release of benefits. Signature Doctor s full name Address Phone number Medical qualifications 7 Date Specialist Yes No (if yes, insert specialisation) 19 of 24

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21 Withdrawal Form 1 March 2013 OnePath MasterFund ABN RSE R SFN OnePath Custodians Pty Limited ABN AFSL RSE L Kent Street, Sydney NSW 2000 ANZ Smart Choice Customer Services Phone ANZSmartChoice@anz.com Postal address Please return completed forms to: ANZ Smart Choice Customer Services, Reply Paid 85728, Sydney NSW Member number(s) Member number(s) 2. Name of applicant Surname Given names(s) Current address Date of birth State Office hours phone number Postcode 3. Direct Credit Facility Payments will be credited directly to your Bank/Building Society/Credit Union account. Please provide your full details below. NB: Direct crediting may not be available on a full range of account types. Please check with your financial institution. Name of Bank/Credit Union/Building Society Account Holder s Name Bank (BSB Number) Account number 4. Tax File Number (TFN) Notification Your Tax File Number Information you should know about providing your Tax File Number The collection of tax file numbers is authorised by tax laws, the Superannuation Industry Supervision Act 1993 and the Privacy Act OnePath is authorised to collect members tax file numbers on behalf of the Trustee of the Fund (OnePath Custodians Pty Limited ABN AFSL RSE L ). The purposes for which your tax file number is currently authorised to be used include: taxing Eligible Termination Payments at concessional rates; finding and amalgamating your superannuation benefits where insufficient information is available; passing your TFN to the Australian Taxation Office (ATO) where you receive a benefit or have unclaimed superannuation money after reaching the aged pension age; allowing the trustee of your superannuation fund or the provider of your Retirement Savings Account to provide your TFN to another superannuation provider receiving any benefits you may transfer. Your trustee or superannuation provider won t pass your TFN to any other provider if you tell them in writing that you do not want them to pass it on; allowing your superannuation provider to quote your TFN to the ATO when reporting information for the purposes of the Superannuation Contributions Tax (Surcharge). 21 of 24

22 You are not required to provide your TFN. Declining to quote your TFN is not an offence. However, if you do not provide it: you may pay more than you have to on your superannuation benefits (you will get back at the end of the financial year in your income tax assessment); it may be more difficult to find your superannuation benefits if you change your address without notifying your fund or to amalgamate any multiple superannuation accounts; the Superannuation Contributions Tax (Surcharge) may apply to certain contributions and transfers to your superannuation fund; The lawful purposes for which your TFN can be used and the consequences of not quoting your TFN may change in future, as a result of legislative change. Further information is also available from the ATO Superannuation Helpline on Declaration I, (Name) of (Address) hereby declare that I am not bankrupt or insolvent under administration and that the information provided by me in this form is true and correct. I request that the Trustee, OnePath Custodians Pty Limited ABN to act upon and give effect to the directions given by me in this notice. I acknowledge that should I, or my estate receive a payment from OnePath Custodians Pty Limited in full satisfaction of my benefits under the Policy and/or the Fund, OnePath Custodians Pty Limited would have fully discharged their obligations under the Trust Deed governing the Fund and the Policy, and that any payment made to or in respect of me shall be net of the lump sum tax paid, as required by law, to the Australian Tax Office. Signature of Claimant 7 Date Signature of Witness 7 Date Name of Witness (Please print name) Occupation Signature to be witnessed by anyone who is prescribed as being able to witness a Statutory Declaration under the Commonwealth Statutory Declaration Act For example, Australia Post employee, Bank Officer (both must have 5 years continuous service), Justice of the Peace or legal practitioner, except when signed in the presence of an Officer of the Trustee. 22 of 24

23 Know your customer identification requirements Please send in certified copies* (not originals) of the following: one primary photographic identification document or one primary non-photographic identification document and one secondary identification document. Please note: we cannot accept certified copies by fax. Acceptable forms of identification Primary photographic identification document Current Australian or foreign driver s licence Australian passport (current or expired less than 2 years ago) Foreign government issued passport that also contains the holder s signature Proof of Age document issued by a State or Territory Foreign government issued identity card containing the holder s signature Primary non-photographic identification document Australian birth certificate Certificate of Australian citizenship Foreign government issued birth certificate Foreign government issued certificate of citizenship Centrelink pension or health care card Secondary identification document Commonwealth, State or Territory government issued document showing name and residential address and the provision of financial benefits Tax Office issued document showing name and residential address and an amount payable that was issued within the preceding12 months Local government or utility issued document showing name and residential address and the provision of services that was issued within the preceding 3 months. If under the age of 18, a notice from a school principal containing the name and residential address and the period of attendance at that school that was issued within the preceding 3 months. Documents not in English must be accompanied by an English translation prepared by an accredited translator. * A certified copy is a document that has been certified as a true copy of the original by one of the following: a person enrolled on the roll of a Supreme Court or the High Court as a legal practitioner a judge, registrar or deputy registrar of a court a magistrate a chief executive officer of a Commonwealth court a justice of the peace a notary public a police officer an agent of Australia Post in charge of supplying postal services to the public a permanent employee of Australia Post with 2 years continuous service employed in supplying postal services to the public an Australian consular or diplomatic officer an officer with 2 years continuous service with one or more financial institutions a finance company officer with 2 years continuous service with one or more finance companies an officer or authorised representative of an AFSL holder with 2 years continuous service a member of the Institute of Chartered Accountants in Australia, CPA Australia or National Institute of Accountants with 2 years continuous membership. NB The person who is authorised to certify documents must make sure all pages have been certified as true copies by writing or stamping certified true copy followed by their signature, printed name, qualification (eg Justice of the Peace, Australia Post employee, etc) and date. 23 of 24

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