Hospital Claim Form Direct Payment Section 1: Hospital Details - for completion by Hospital Administration Staff (Please place ‘X’ in required boxes) 1.1 Hospital Code: 1.2 Hospital Name: HOSPITAL STAMP REQUIRED FOR GOVERNMENT LEVY : 1.3 Date of Admission: D D M M Y Y 1.4 Time of Admission: H H M M H H:M M 1.5 Date of Discharge: D D M M Y Y 1.6 Time of Discharge: 1.7 Reimbursement Method: FPP 1.8 Hospital Invoice Value: PP € PER DIEM HRS PUBLIC GOVT. LEVY ONLY . 1.9Hospital Admission (Please provide details of all accommodation occupied during admission including Intensive Care Unit (ICU), Coronary Care Unit (CCU) and Neonatal Intensive Care Unit (NICU)): Type of Ward: Please Ward Name/Number: Room Name/Number: ‘X’ Bed Number: Number of Beds in Room: Number of Days: Private Room Semi-Private Room Public Ward Day Ward ICU/NICU CCU 1.10 Treatment Setting (If the patient was not admitted to a ward in the hospital, please specify the treatment setting): Theatre Sideroom Out-patient Dept. A&E Dept. Radiology Centre 1.11 Was the patient transferred directly from another facility for this procedure? Yes Consultant/GP Rooms Minor Injury Unit No If yes, name other facility: Section 2: Policy Details - for completion by Policy Holder/Member (Please place ‘X’ in required boxes) 2.1 Quote Policy No. Here: from your Vhi membership card. 2.2 Policy Holder’s Name: 2.5 Patient’s Name: 2.3 Policy Holder’s Address: 2.6 Patient’s Date of Birth: 2.7 Contact Telephone No.: 2.4 Is this the Policy Holder’s permanent address? Yes No D D MM Y Y 2.8 Email Address: Section 3: History of Illness - for completion by the Policy Holder/Member (Please place ‘X’ in required boxes) 3.1 Name of doctor first attended: 3.2 Date of first consultation: D D MM Y Y 3.3 Doctor’s Address: D D MM Y Y JULY 2015 HDCF11 3.4When was it first made known to you that this particular investigation/treatment (which is the subject of this claim) was required? 3.5 Has this patient had this or a similar illness before? Yes No 3.6 If Yes, please give date and details: Date: D D MM Y Y Details: 3.7 Are any of these expenses fully or partially recoverable from any other source? Yes No 3.8 If Yes, please give details: 3.9 How many weeks did you wait for an out-patient appointment with your consultant following your GP referral? 3.10When your consultant decided that admission to hospital was necessary, how many weeks were you waiting for your admission? 3.11Did you elect to be a private patient of the admitting consultant? Yes No 3.12If transferred from a public facility, did you elect to be a private patient of the admitting consultant in that facility? Yes 3.13Is your admission/treatment related to a Clinical Research Study? Yes No No Section 4: Injury Details - for completion in all cases involving injury (even if no third party is involved) (Please place ‘X’ in required boxes) 4.1 Date of injury: D D MM Y Y 4.2 Place of injury: 4.3 Brief description of how the injury occurred: 4.4 Do you intend to pursue a legal claim against a third party (parties)? Yes No 4.5 Name and address of solicitor (where applicable): In consideration of Vhi discharging my hospital and medical expenses to the extent of my cover limits and in accordance with the Rules of my contract with Vhi, I agree to include these expenses as part of my current (or future) claim against a third party(ies). Where I pursue a claim against a third party, either through the Courts or other Tribunals/Boards (and where I have legal representation), I hereby irrevocably authorise the solicitor(s) representing me in making that claim to furnish to Vhi an undertaking in the following form: “In consideration of Vhi discharging the eligible hospital and medical expenses of my client, I hereby agree to include as part of my client’s claim the monies so paid by Vhi (details of which will be supplied to me by Vhi) and subject to any court order to the contrary, to repay to Vhi - out of the net proceeds of the settlement that come into our hands - all monies recovered in respect of such expenses paid by Vhi.” Where my claim is adjudicated upon by the Injuries Board or the Criminal Injuries Compensation Tribunal and where I do not engage legal representation, I hereby agree to include as part of my claim the monies so paid by Vhi (details of which will be supplied to me by Vhi) and subject to any order/award to the contrary, to repay to Vhi - out of the net proceeds of the settlement that come into our hands - all monies recovered in respect of such expenses paid by Vhi. I further authorise Vhi to provide the Injuries Board and/or my legal representative with details of all claims paid by Vhi relating to my third party case and for the Injuries Board/my legal representative to release to Vhi full details of the Injuries Board assessment or other agreed settlement with a third party. In circumstances of an anticipated reduced settlement I agree to contact Vhi upon it being made known to me that monies so paid by Vhi may not be fully recoverable. When a reduced settlement has been agreed, I will provide Vhi with a Certificate from my legal representatives in the format agreed between the Law Society and Vhi confirming that the net proceeds recovered is the amount actually recovered. In addition, I agree to provide a Certificate from Counsel (if Counsel was instructed in relation to the settlement/hearing), confirming the veracity of the net proceeds recovered. Section 5: Policy Holder/Member Authorisation Data Protection and Consent The personal data and sensitive personal data that you provide to the Vhi Group (“Vhi”) in this Claim Form, or which you authorise third parties to provide, will be used within the Vhi group of companies for claims processing, claims auditing (including clinical and billing audits), policy administration and customer care purposes. Data may also be used for statistical analyses and the detection and prevention of fraud. We may share your data with trusted third parties who process data or conduct clinical and/or billing audits on our behalf, inside and outside of the European Economic Area. We may also share your data with other insurers to verify your cover, and with state bodies as required by law. Clinical audit is a clinically led quality improvement process that seeks to improve patient care and outcomes through the systematic review of care against explicit criteria and to act to improve care where standards are not met. I confirm that I give explicit consent to my data, including up-to-date medical diagnoses information, being held, used and processed for the purposes described above, including the purpose of undertaking investigations into, and to adjudicate on, my claim (including the length of my hospital stay and the treatment I received) and for the purposes of Vhi providing me with information about products and services aimed at managing my health and wellbeing. You have the right, subject to certain exemptions, to access any of your personal data that we hold (for which we may charge you a small fee) and to have inaccuracies corrected. If you wish to avail of these rights, please write to the Data Protection Officer, Vhi House, 20 Lower Abbey Street, Dublin 1. Vhi’s Data Protection Statement contains a further detailed breakdown of the personal data we collect in relation to our customers and how we use that personal data. The Data Protection Statement can be found at www.vhi.ie or should you wish to contact us on 1890 44 44 44, you can request a hard copy. Declaration: I declare that the information completed above at the time of signing this declaration is true in every respect. I authorise the medical practitioner/treatment facility concerned to supply all necessary information to Vhi or its duly authorised agents acting on its behalf including, if requested, copies of my hospital/medical records in relation to this claim regarding treatment or services received by me. I also authorise Vhi to pay the appropriate benefits for services provided to the treatment facility and medical practitioners concerned. I understand that details of these amounts will be included in my Vhi statement of payment, and I will contact Vhi directly with any queries. Charges which are not eligible for benefit will remain my responsibility to settle directly with the medical practitioner/treatment facility concerned. X Policy Holder’s/Member’s Signature (You must sign here) Date: D D MM Y Y Claims statements are normally sent to the subscriber of the policy. If you are the claimant in this instance, but you are not the subscriber and you wish to have the claims statement sent to you directly, please phone us on 1890 44 44 44 or visit us at www.vhi.ie/contact/. Please note the address you provide in Section 2 is used purely for data validation purposes. If you need to update your contact details or membership/personal data, please contact our Customer Service Helpline at 1890 44 44 44. Vhi Insurance Limited trading as Vhi Insurance is regulated by the Central Bank of Ireland. JULY 2015 HDCF11 Please check that you have entered your Policy Number.
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