Hospital Claim Form

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.