Dr J Markham Dr P Duffus Dr D Kreis-Alsayed Dr A Davey Dr A Al Sawaf Dr A Prasad Dr K Salmon Dr B Spencer Dr G Khalsa
|
|
|
- Gordon Wright
- 6 years ago
- Views:
Transcription
1 FEES PAYABLE FOR NON-NHS SERVICES Please make cheques payable to Elizabeth Courtauld Partnership, not to the Doctor. Thank you ITEM PAID BY FEE ACCESS TO MEDICAL RECORDS Medical Records Perusal (Under supervision) Patient Medical Records - Copy of computerised Patient records Medical Records - Copy of manual and/or manual and computer records Patient ADOPTION Adoption Medical Forms (NHS recommendation) ATTENDANCE ALLOWANCE GP Factual Report DWP DS1500 Form DWP CERTIFICATES Passport Photo/ Private sick note Patient Freedom from infection Patient Private certificate non NHS Patient Shotgun Licence Patient Fitness to travel/fly/exam etc Patient Fitness to exercise Patient Holiday cancellation Patient CHILDMINDER Ofsted Health Declaration Form Patient/ Employer CONSULTATION Private Consultation Per Hour pro rata Patient Private Consultation (10 minutes) Patient CREMATION Cremation Fees (Form 4, Form 5) Family ECG Private ECG 61.00
2 FOREIGN VISITORS CHARGES GP Consultation only (10mins) Patient Referral for other care Patient Further list for Foreign Visitors on boards in reception HEP B Hep B course of 3 Employer Single immunisation of HepB not for travel Patient Follow up blood test Employer/ Patient MCA2 FORMS Consultation in surgery Patient Consultation in patient s home Patient MEDICALS - EMPLOYER Full medical report (45 Mins) Employer Letter record extract no exam (15 mins) Employer Letter - record extract (no exam) Solicitors MEDICALS - INSURANCE GPR/ egpr Insurance Company Own patient Insurance Company Questionnaire Insurance Company Supplementary info Insurance Company Targeted Report Insurance Company BP Report Insurance Company Blood Test Insurance Company MEDICALS - PRIVATE HGV/PSV Medical (45 mins) Patient Taxi medical (20 mins) Patient Pilots and racing licence Patient Fitness to drive exam report for elderly Patient Slimming Medical Patient DVLA Medical report DVLA PATERNITY TESTING Orchid Cellmark (Oxford) Tel Oxford Tel Three (3) sample mouth swab tests Sample kit sent to sampler (GP or appointed doctor) Patient VAT Sample taken by GP or chosen doctor Orchid to pay GP 30.00/
3 sample University Diagnostics Ltd (London ) Tel Three sample kit (mouth swabs) VAT = Registration can be requested online, to be returned, acting as consent, with payment or legal aid certificate. Results in five working days of receipt of samples. Sample taken by GP or chosen doctor UD to pay GP 30.00/ sample POWER OF ATTORNEY Witnessing of Power of Attorney/wills Patient Travel time to be charged extra Patient Power of Attorney assessment Patient /hr Travel time to be charged extra Patient RECORDS Medical Records Perusal (Under supervision) Patient Medical Records - Copy of computerised Patient records Medical Records - Copy of manual and/or manual and computer records Patient SMEAR TESTS Private smear tests (surgery fee) Private smear tests (lab fee) Patient will be directly invoiced by the lab for cytology TRAVEL Single Immunisation for travel Patient Course of three immunisations for travel Patient Yellow fever Patient Issuing copy of YF Certificate Patient 16.30
4 INVOICE/ RECEIPT BOOK PRICE LIST Passport Photo/Private Sick Note Short letter to employer Short insurance claim form (dates, diagnosis signature) Medium Insurance Claim Form (short report/ extract from notes) Long Insurance Claim Form (Full report and Prognosis) Medium Examination (Taxi/HGV/Insurance/Slimming N/A N/A Taxi HGV/PSV Insurance N/A Slimming Pilot Single immunisation for travel Course of three immunisations for travel Yellow Fever Hep B (course of three) Follow up blood test Private smear tests (surgery fee) Cytology, patient invoiced directly by lab Other or Foreign visitor charge Total to patient per 10 min consultation
5 FEES FOR NON-NHS SERVICES Passport Photo/Private Sick Note Holiday Cancellation Letter Fitness to fly/ travel letter Insurance Claim Form Shotgun Licence Fitness to exercise Ofsted Report (Paid by Patient) HGV/PSV Medical Single immunisation for travel Course of three Immunisations for Travel Yellow Fever Hep B (course of three injections) Follow up blood test Private smear tests (surgery fee) Cytology, lab fee (invoiced directly by lab) Other or Foreign Visitor Charge (Total 86.25) per 10 min consultation Fees valid for
Fee Guidance for GPs who receive Information Requests
The Access to Health Records Act 1990 (AHRA) provides a small cohort of people with a statutory right of to apply for access to information contained within a deceased person s health record. Any requests
It is important to understand that many GPs are not employed by the NHS.
Last updated: 30 June 2016 Why GPs sometimes charge fees Surely the doctor is being paid anyway? It is important to understand that many GPs are not employed by the NHS. They are self-employed and they
Who to call for an emergency: Name: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Relationship:
Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one) Married/Single/Divorced/Widow Address: Zip Code: Home Phone: ( ) - E-mail Address: Cell Phone:
Office and Financial Policies
Office and Financial Policies Thank you for reviewing the following office and financial policies. We commit to put forward our best efforts to provide you with the most up to date, skilled, and compassionate
When we receive your claim submission, we will assess it and correspond with you further in due course.
Travel Insurance Boots Travel Claims PO Box 60108 London SW20 8US Tel: 0845 125 3820 Fax: 0870 130 1950 Dear Sir / Madam, So that we may process your claim as quickly as possible please ensure that you
Primary Care Commissioning Committee
Primary Care Commissioning Committee DETAILS Part 1 (Open) x Part 2 (Closed) Agenda Item 4.1 Meeting Primary Care Commissioning Committee Date 12 October 2017 Title of Paper Finance Report August 2017
How to navigate financial benefits
How to navigate financial benefits David Gibb Edinburgh Macmillan Welfare Benefits Partnership 9 September 2017 1 Just imagine... You get told today You are no longer able to work full time You will not
NHS Pensions - Pension Credit Member - Consideration of entitlement for early payment of deferred benefits due to ill health (AW240(PC))
NHS Pensions - Pension Credit Member - Consideration of entitlement for early payment of deferred benefits due to ill health (AW240(PC)) Before completing this form please read the notes below. We normally
When we receive your claim submission, we will assess it and correspond with you further in due course.
Travel Insurance Boots Travel Claims PO Box 60108 London SW20 8US Tel: 0845 125 3820 Fax: 0870 130 1950 Dear Sir / Madam, So that we may process your claim as quickly as possible please ensure that you
PATIENT INFORMATION & PREFERENCES (Please print or type) YOUR MAJOR HEALTH CONCERNS OR QUESTIONS
Dear Patient: The following questions are designed to collect important information about you and your health. Answering these questions before your office visit will allow more time for a detailed discussion
Summary of 2017/18 General Medical Services Contract Negotiations
NHS Cumbria CCG - Primary Care Commissioning Committee Agenda Item 11 May 2017 8 Summary of 2017/18 General Medical Services Contract Negotiations Purpose of the Report To provide a summary to the Committee
January 2005 GPC. General Practitioners Committee. Model GP retainer scheme contract
January 2005 GPC General Practitioners Committee Model GP retainer scheme contract Model Contract of Employment for a Retainer Scheme GP Parties and Appointment 1. This contract is dated the day of 200.
PERSONAL HEALTHCARE BENEFITS AT A GLANCE FROM VITALITYHEALTH VITALITY.CO.UK/HEALTH
PERSONAL HEALTHCARE BENEFITS AT A GLANCE FROM VITALITYHEALTH VITALITY.CO.UK/HEALTH BENEFITS AT A GLANCE WITHIN THIS DOCUMENT YOU WILL FIND THE BENEFITS AND COVER OPTIONS YOU COULD HAVE WITH A PERSONAL
Lowrance Dental REGISTRATION FORM (Please Print)
Today s Date: Patient s last name: First: Middle: Lowrance Dental REGISTRATION FORM (Please Print) PCP: PATIENT INFORMATION Mr. Mrs. Miss Ms. Marital status: Single Mar Div Sep Wid Is this your legal name?
Personal Accident. Claim Form. Important Notes
Personal Accident Claim Form Important Notes This claim form is to facilitate your claim in the event of you or a member of your family is confined to hospital while being Insured under a Personal Accident
The Life Protector Plan
The Life Protector Plan Application for Assurance Life Protector (an Annually Renewable Life assurance) pays a lump sum in the event of death by natural or accidental cause. Policy carries a five year
Patient Name: Last name First Name Middle Initial. Address: Street or Box City State Zip Phone: (Primary) (Cell) (Other) Date of Birth:
PATIENT REGISTRATION FORM Patient Name: Last name First Name Middle Initial Address: Street or Box City State Zip Phone: (Primary) (Cell) (Other) Date of Birth: Email: Gender: o Male o Female SSN# Marital
will be able to help you. d d mm y y
Personal Accident Claim Form This form has been designed to help you provide all the information we need to process your claim quickly. Failure to complete this form correctly may delay your claim. We
CHECKLIST OF DOCUMENTS REQUIRED. DOCUMENTATION SHOWING YOUR TRAVEL DATES AND FULL COST OF THE TRIP (booking invoice)
PA PERSONAL ACCIDENT Dear Customer, Travel Claims Facilities PO Box 395 Monks Green Farm Mangrove Lane Hertford SG13 9JW Email: claims@tif-plc.co.uk Web: www.tifgroup.co.uk In order that we can process
Primary Care Commissioning Committee (PCCC) Finance Paper November 2017
Primary Care Commissioning Committee (PCCC) Finance Paper November 2017 1.1 CCG Finance Update Shown below is a summary of the financial position to 30 th November 2017 of the areas of Primary Care spend
What to bring to first appointment. You must have with you any related allergy testing, lab results, CT Scan or X-ray results, biopsy
Jayanti J. Rao, M.D. Shaili N. Shah, M.D. What to bring to first appointment You must have with you any related allergy testing, lab results, CT Scan or X-ray results, biopsy results, list of current medications,
Charitable Funds. Target Audience. Who Should Read This Policy. All Clinical/Non Clinical Staff
Charitable Funds Who Should Read This Policy Target Audience All Clinical/Non Clinical Staff Version 1.0 April 2017 Ref. Contents Page 1.0 Introduction 4 2.0 Purpose 4 3.0 Objectives 4 4.0 Process 4 4.1
VISITORS TO CANADA Insurance Claim Form
Claims Administration OLD REPUBLIC INSURANCE COMPANY OF CANADA RELIABLE LIFE INSURANCE COMPANY Box 557, 100 King Street West Hamilton, Ontario L8N 3K9 Toll Free: 888.831.2222 Fax: 866.551.1704 VISITORS
PLAN COMPARISON (Blue Cross Blue Shield of Massachusetts) For Members Who Are Eligible For Medicare
Quarterly Premium Rate * Per Person $2,215.08 $1,789.50 $618.99 $890.70 Rates effective: 1/1/16 through 12/31/16 1/1/16 through 12/31/16 1/1/16 through 12/31/16 1/1/16 through 12/31/16 Eligibility Service
PLAN COMPARISON (Blue Cross Blue Shield of Massachusetts) For Members Who Are Eligible For Medicare
Quarterly Premium Rate * Per Person $2,358.60 $1,905.33 $658.74 $1,165.11 Rates effective: 1/1/17 through 12/31/17 1/1/17 through 12/31/17 1/1/17 through 12/31/17 1/1/17 through 12/31/17 Eligibility Service
To begin the medical second opinion process, please complete the following steps:
The purpose of the Medical Second Opinion (MSO) program of Johns Hopkins Medicine International is to provide information to the patient or the local treating physician so that an informed decision can
Patient Name: Date of Birth: Last name, First Name. Address: Street, City, State, Zip. Cell Phone: Home Phone: Work Phone:
Center for Pediatric Adolescent Gynecology INSURANCE INFORMATION/PATIENT AGREEMENT Patient Name: Date of Birth: Last name, First Name Address: Street, City, State, Zip Email: Cell Phone: Home Phone: Work
CANCELLATION BEFORE DEPARTURE OF A TRIP
CA CANCELLATION BEFORE DEPARTURE OF A TRIP Travel Claims Facilities PO Box 395 Monks Green Farm Mangrove Lane Hertford SG13 9JW Email: claims@tif-plc.co.uk Web: www.tifgroup.co.uk Dear Customer, In order
Patient Fare Reimbursement Procedure
Patient Fare Reimbursement Procedure Version: 2.3 Bodies consulted: na Approved by: PASC Date Approved: 12.5.16 Lead Manager: General Office Manager Lead Director: Deputy Chief Executive Date issued: May
CURTAILMENT OF A TRIP
C CURTAILMENT OF A TRIP Travel Claims Facilities PO Box 395 Monks Green Farm Mangrove Lane Hertford SG13 9JW Email: claims@tifgroup.co.uk Web: www.tifgroup.co.uk/services/claims Dear Customer, In order
NATIONAL HEALTH SERVICE, ENGLAND. The General Medical Services Statement of Financial. Entitlements (Amendment) Directions 2017.
FINAL D I R E C T I O N S NATIONAL HEALTH SERVICE, ENGLAND The General Medical Services Statement of Financial Entitlements (Amendment) Directions 2017 The Secretary of State for Health gives the following
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
Work Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days
Travel Insurance Claim Form Cancellation You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend to rely on for your claim,
Credit card holder travel insurance claim form
Credit card holder travel insurance claim form QBE Insurance (Australia) Limited ABN 78 003 191 035 AFSL 239 545 Office use only Claim number Please answer all questions and tick boxes where appropriate
APPLICATION FOR ASSISTANCE (CHILDREN)
WORLD CRANIOFACIAL FOUNDATION Medical City Dallas 7777 Forest Lane Suite C-621 Dallas, Texas 75230 Mailing Address: P.O. Box 515838 Dallas, Texas 75251-5838 Telephone (972) 566-6669 800-533-3315 APPLICATION
Sammy Lerma III, M.D. P.A. History and Physical Name: DOB: Age:
History and Physical Name: DOB: Age: Reason for Visit : Current Medications: Previous Hospitalizations: Last Physician's Name: Previous Surgeries: Reason for Changing Physicians: Current Specialists: Medication
Medicare Set-Aside Arrangements. Centers for Medicare & Medicaid Services
Medicare Set-Aside Arrangements Centers for Medicare & Medicaid Services 1 Final Settlement Agreement Authorization Workers Compensation Medicare Set-aside Arrangement (Amount/Proposal) Diagnosis Codes
Application for injury benefit assessment
CSIBS1 - P1 PROTECT - STAFF Civil Service Injury Benefit Scheme Application for injury benefit assessment Part 1 Member to complete Capita Health & Wellbeing are medical advisers to the Civil Service Pension
PATIENT REGISTRATION FORM
Today s Date / / PATIENT REGISTRATION FORM PATIENT INFORMATION Patient Name Last First Middle Is this your legal name? If not, what is your legal name? Birthdate Age Sex q YES q NO / / q M q F q T Street
Nothing is more important than your health. With Pallas GlobalHealth, you get the best possible care in case of illness or injury.
Nothing is more important than your health With Pallas GlobalHealth, you get the best possible care in case of illness or injury. Valid from 1 January 2013 Contents About Pallas GlobalHealth 1 Plan Highlights
CURTAILMENT CLAIM FORM
Staysure Claims 308-314 London Road, Hadleigh, Benfleet, Essex SS7 2DD Tel: 01403 288410 Fax: 01702 427173 email: info@csal.co.uk / www.csal.co.uk Please use the address to the left for ALL correspondence
Medical Emergency and Associated Expenses
TRAVEL INSURANCE CLAIM FORM Medical Emergency and Associated Expenses You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend
Disability Claim Form
Disability Claim Form Instructions for Filing a Claim SUBMITTING AN APPLICATION All sections of this application must be completed and sent to If the claim form is not completed in full, processing of
Patient Information. Parent or Responsible Party. Patient Authorization and Financial Responsibility
Patient Information Name Last First M.I. Mailing Address Street Apt# City State Zip HomePhone WorkPhone CellPhone Email Date of Birth / / Age Sex Marital Status Parent or Responsible Party Name Last First
PERSONAL HEALTHCARE BENEFITS AT A GLANCE FROM VITALITYHEALTH VITALITYHEALTH.CO.UK
PERSONAL HEALTHCARE BENEFITS AT A GLANCE FROM VITALITYHEALTH VITALITYHEALTH.CO.UK BENEFITS AT A GLANCE WITHIN THIS DOCUMENT YOU WILL FIND THE BENEFITS AND COVER OPTIONS YOU COULD HAVE WITH A PERSONAL
NHS BEXLEY CLINICAL COMMISSIONING GROUP. Policy in relation to terms and conditions for members of the Governing Body
NHS BEXLEY CLINICAL COMMISSIONING GROUP Policy in relation to terms and conditions for members of the Governing Body Author s name & Title: Simon Evans-Evans, Director of Governance and Quality Sponsor
TEAM TRAVEL MANUAL. Table of Contents. I. General Info About Belize Project Important Dates & Deadlines
TEAM TRAVEL MANUAL Table of Contents I. General Info About Belize Project Important Dates & Deadlines II. Forms Interest Form Important Details and Paperwork Travel Agreement Form Emergency Data Form Passport
Claim Form - Travel Insurance
Claim Form - Travel Insurance Important tice: To enable us to process your claim, please submit the duly completed claim form with supporting documents in original as listed in the subsequent section.
NRMA Income Protection Sickness or Injury Initial Medical Report
NRMA Income Protection Sickness or Injury Initial Medical Report (To be completed by your Medical Practitioner) Please ensure that: ALL questions are completely answered to avoid any undue delays to this
Finance and Resources Committee 17 March 2010
Finance and Resources Committee 17 March 2010 Expenses Policies Executive Summary and Recommendations Introduction At the July 2009 meeting of the Finance and Resources Committee, consideration was given
PROPOSAL / APPLICATION INDIVIDUAL ACCIDENTAL DEATH INSURANCE
PROPOSAL / APPLICATION INDIVIDUAL ACCIDENTAL DEATH INSURANCE Lloyd s of London Correspondents: Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122,
CLAIM FORM FREQUENTLY ASKED QUESTIONS
CLAIM FORM FREQUENTLY ASKED QUESTIONS Q: How long will it take for me to receive a response to my claim? A: We are committed to provide a quality service, our claims team will review the documentation
UNITED LEARNING TRUST RETENTION GUIDELINES
UNITED LEARNING TRUST RETENTION GUIDELINES This retention schedule contains recommended retention periods for the different record series created and maintained by academies in the course of their business.
In addition there are several aspects of your disability claim that you should be aware of:
Dear Colleague: American Airlines has partnered with Harvey Watt and Company as the Claim Administrator for the Pilot Long Term Disability Plan (the Plan). We have enclosed the Claim Application along
Name Social Sec. # Date of Birth Male/Female First MI Last. Address City State Zip. Home Phone Cell Phone . Employer Occupation Work Phone
LONDON BRIDGE SMILES Patient Information (please print) Name Social Sec. # Date of Birth Male/Female First MI Last Address City State Zip Home Phone Cell Phone E-mail Employer Occupation Work Phone Business
BLAKE FRIEDEN MD, PA Registration Form
BLAKE FRIEDEN MD, PA Registration Form Name: Today s Date: First Middle Last Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Cell Phone: ( ) Social Security Number - - Race/Ethnicity: White
Protocol in respect of locum cover or GP performer payments for parental and sickness leave
Protocol in respect of locum cover or GP performer payments for parental and sickness leave 2 Protocol in respect of locum cover or GP performer payments for parental and sickness leave Version number:
PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /
![PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /](/thumbs/85/92736920.jpg "PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /")
Dr. Osehotue Okojie, M.D. Godwin Okojie, P.A. Patient Registration Form (Please Print) PATIENT INFORMATION PATIENT S NAME: Last name First name Middle Birth Date: / / Sex: [ ] M [ ] F Social Security #:
Willow Bend OB/GYN Obstetrics, Gynecology & Infertility
Dear Patient, Welcome to our medical office. We look forward to meeting you soon. In order to provide you with the best possible care, please complete our registration forms prior to your first visit and
PARKVIEW PRIMARY CARE PHYSICIANS 20 Losson Road, Suite 105 Cheektowaga, NewYork (716) Fax (716)
Orville Hendricks, M.D. John Kavcic, M.D. Deirdre Bastible, M.D. PARKVIEW PRIMARY CARE PHYSICIANS 20 Losson Road, Suite 105 Cheektowaga, NewYork 14227 (716)558-7727 Fax (716)558-7720 Office Policy (revised
Travel Insurance Claim Form
IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for us to return your claim forms or lead us to ask more
Medical aid patients
Praktice Billing Policy Out-of-hospital Consultations July 1, 2018 Medical aid patients 1. Medical aid patients belonging to a contracted medical aid and without the need for a GP referral or authorization
Welcome to Sibley Primary Care
Welcome to Sibley Primary Care We are pleased to have you join our practice. We understand that starting with a practice can be overwhelming and we ve provided this welcome packet to aid with your first
Please bring the medications you are currently taking. If you had x- rays made, please bring the films with you when you come to the office.
Dear Patient: We would like to take this opportunity to thank you for choosing our office for your urologic care and to welcome you to our office. We are pleased that you have chosen us to provide you
A plan designed to work for you.
YOUR ADVANTAGE: A plan designed to work for you. 2019 Benefit Plan NMRHCA Plan Benefits and Features Group Medicare Advantage PPO Plans Your Medicare Advantage plan The advantages of a single plan. Medicare
REIMBURSEMENT OF PATIENT TRAVEL COSTS POLICY AND PROCEDURES MAY 2018
REIMBURSEMENT OF PATIENT TRAVEL COSTS POLICY AND PROCEDURES MAY 2018 This policy supersedes all previous procedural documents for patient travel claims Policy title Reimbursement of patient Travel Costs
New Patient Registration Packet
New Patient Registration Packet This Patient Registration Packet includes the following: 1. Patient Registration Sheet (page 1) This form is for patient demographic and physician referral information.
Title of meeting Primary Care Commissioning Agenda item 8. Part 1. Date of meeting 24 April 2017 Confirm part one or two
Title of meeting Primary Care Commissioning Agenda item 8 Committee Date of meeting 24 April 2017 Confirm part one or two Part 1 Title of paper Outcome of 2017/18 GMS Contract Negotiations Director Fran
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA Poonam Singh, M.D. * Elizabeth Sanchez Fowler, M.D. * Tonya Suffridge, M.D. * Anuradha Venkatachalam, M.D. Balbir Singh,
Cardiology Consultants of Atlanta, P.C N. Decatur Rd. Suite 395, Decatur GA, (404) phone (678) fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
1. Personal Details and Academic History Compulsory
Registration form for ICB Face to Face Courses PLEASE NOTE: CATEGORY 1 TO 4 MUST BE COMPLETED BY ALL STUDENTS. 1. Personal Details and Academic History Compulsory Mr Mrs Miss Ms Other Initials Surname
R.G.C.C. GROUP MEDICAL FORM
R.G.C.C. MEDICAL FORM R.G.C.C. Medical Order Form Vial Number: Contact Details: PATIENT S NAME :... GENDER : F M ADDRESS :... CITY :... E-mail :... D.O.B. (dd/mm/yy) :... COUNTRY :... P. O. / ZIP CODE
NT/18/205. Permanent part-time Clerical Officer- 25 hpw. Saintfield High School, Ballynahinch. Candidate Information Pack
NT/18/205 Permanent part-time Clerical Officer- 25 hpw Saintfield High School, Ballynahinch Candidate Information Pack JOB DESCRIPTION POST: LOCATION: HOURS: Clerical Officer (Post available from 21 August
GREENWOOD DERMATOLOGY
GREENWOOD DERMATOLOGY Larry J. Buckel, M.D. Thomas J. Eads, M.D. Laura T. Stitle, M.D. Thank you for choosing Greenwood Dermatology for your Dermatologic needs. Dermatologists are the experts in the diagnosis
AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED HEALTH INFORMATION
AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED HEALTH INFORMATION I understand the following: I have the right to refuse to sign this form for authorization to disclose or release my protected health
CANCELLATION / CURTAILMENT CLAIM FORM IMPORTANT - PLEASE READ THE FOLLOWING CAREFULLY AND ENCLOSE THE DOCUMENTS REQUESTED
Fogg Travel Insurance Services Limited Crow Hill Drive, Mansfield, Nottinghamshire, NG19 7AE telephone 01623 631331 fax 01623 420450 email claims@foggtravelinsurance.com CANCELLATION / CURTAILMENT CLAIM
AmeriHealth Medigap Plans Information. Individual health plan options for people with Medicare
2016 AmeriHealth Medigap Plans Information Individual health plan options for people with Medicare AM6830 (5/15) 5823(10/15)BKV1 Thank you. We appreciate your interest in AmeriHealth New Jersey. We look
Any fee charged by the member s GP for providing information for completion of the claim form will not be covered.
TRAVEL COVER CLAIM FORM FILLING IN THIS FORM Please fill in this form if a claim is being made from the Worldwide Travel Cover. Complete this form in black ink and as fully and truthfully as possible.
VERSION Version 5 SUMMARY The policy sets out rules for the reimbursement of travel, accommodation and subsistence expenditure APPROVAL Approved by
TITLE Expenses Policy VERSION Version 5 SUMMARY The policy sets out rules for the reimbursement of travel, accommodation and subsistence expenditure APPROVAL Approved by the Remuneration Committee on 1
NEW & CURRENT PATIENTS
Patient Registration Update: NEW & CURRENT PATIENTS General Information: First Name: MI: Last Name: Prefix: Suffix: Address: Zip Code: City: State: Contact: Cell: Home: Work: Email: Insurance Information:
SECTION 1 (To be completed by the Life Assured who is at least 18 years old or the Policyowner if the Life Assured is below 18 years old)
C041017 TERMINAL ILLNESS CLAIM FORM PruCustomer Line: 1800-333 0 3333 Important tes 1. Please note that, under the policy terms and conditions, the policy may be void if any information provided in this
Surname Given names Date of birth / / Address State Postcode. please advise police station or first aid service to which the accident was reported
Claim form Income replacement This form is to be completed by the life insured. To be completed only on the request of the Zurich claims area. To avoid delays, check that all questions have been answered
Nationwide Life Ins. Co.: Rhode Island College Coverage Period: 8/15/13-8/15/14
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important
PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code:
PATIENT INFORMATION PATIENT INFORMATION First Name: Last Name: Middle Initial: Nickname: Date of Birth: Sex: Marital Status: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: How did you hear
2. Details of the Claimant if different than the Life Assured (To be filled by person entitled to receive claim proceeds under the policy):
CLAIM INTIMATION - CUM - CLAIMANT S STATEMENT (CRITICAL ILLNESS RIDER / MAJOR SURGERY ASSISTANCE RIDER ) (Format : AP) Guidelines/ Notes: 1. The benefit is payable subject to the policy being inforce on
Cancellation Expenses Claim Form
Please complete this claim fully and return to us by following the postal instructions below. Please return your completed form to: Staysure Trip Cancellation Claims PO Box 9 Mansfield Nottinghamshire
Stonebridge Adult Medicine, P.A. Registration Form (Please Print)
Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female
Small Self-Administered Scheme SSAS. Takeover Application.
Small Self-Administered Scheme SSAS Takeover Application www.investaccpensions.co.uk Contents Company Information 2 Scheme Information 4 Additional Information 5 Member Information (1) 11 Member Information
Group Hospital and Surgical Claim Form
NTUC Income Insurance Co-operative Limited Income Centre 75 Bras Basah Road Singapore 189557 Tel: 6332 1133 Fax: 6338 1500 Email: healthcare@income.com.sg Website: www.income.com.sg Group Hospital and
Welcome to the Joslin Diabetes Center at Baptist Health Medical Group
Welcome to the Joslin Diabetes Center at Baptist Health Medical Group Welcome to the Joslin Diabetes Center. We ve assembled this packet to help answer any questions you might have. Please bring your insurance
Claim Form Cancellation / Curtailment
Claim Form Cancellation / Curtailment Chubb European Group Limited Claims Department PO Box 682 Winchester SO23 5AG T: 0345 841 0059 F: 0141 285 2901 uk.claims@chubb.com Please write in black ink and use
APPLICATION FOR ASSISTANCE (ADULTS)
WORLD CRANIOFACIAL FOUNDATION Medical City Dallas 7777 Forest Lane Suite C-621 Dallas, Texas 75230 Mailing Address: P.O. Box 515838 Dallas, Texas 75251-5838 Telephone (972) 566-6669 1-800-533-3315 APPLICATION
CANCELLATION CLAIM FORM
Avanti Claims 308-314 London Road, Hadleigh, Benfleet, Essex SS7 2DD Tel: 01403 288122 Fax: 01702 427173 email: info@csal.co.uk www.csal.co.uk Please use the address to the left for ALL correspondence
Employers Guide to Operating the Pension Scheme
Employers Guide to Operating the Pension Scheme PLUMBING & MECHANICAL SERVICES (UK) INDUSTRY PENSION SCHEME GUIDE TO OPERATING THE PENSION SCHEME Contents Page 1. Accounting for Pension Scheme 1 2. Additional
Section 1 Customer and travel details (to be completed in all cases)
AWP Services (Thailand) Co., Ltd. 7th Floor, City Link Tower 1091/335 Soi Petchburi 35 New Petchburi Road, Makkasan, Rajthevi, Bangkok 10400, Thailand Tel. +66 (0) 2 305 8533 Fax +66 (0) 2 305 8523 Email
Help with health costs
Help with health costs There are a number of benefits and entitlements available to help older people with the cost of healthcare, such as prescription costs, dental treatment, eye tests and travel to
Patient Registration Form
Patient Registration Form Name: Last First MI Today s Date: Address: Street City State Zip Phone: Best # Daytime # Cell # Date of Birth: Male Female Occupation: Employer: Social Security #: Email: Spouse
PERSONAL ACCIDENT CLAIM FORM
PERSONAL ACCIDENT CLAIM FORM Please complete this form ( including Access to Medical Records & Reports form ) in BLOCK CAPITALS and return it to Rightpath Claims as soon as possible with the following
CLAIM FORM FREQUENTLY ASKED QUESTIONS
CLAIM FORM FREQUENTLY ASKED QUESTIONS Q: How long will it take for me to receive a response to my claim? A: We are committed to provide a quality service, our claims team will review the documentation
CANCELLATION CLAIM FORM
Avanti Claims 308-314 London Road, Hadleigh, Benfleet, Essex SS7 2DD Tel: 01403 288122 Fax: 01702 427173 email: info@csal.co.uk www.csal.co.uk Please use the address to the left for ALL correspondence