Transcription of He al th C l ai m F orm - Atlas
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He al th C l ai m F orm - Atlas
Provide these if you are insured through a companyPlease provide these details so that we can identify your policyHelp us keep your data updated Update any details changed since you last claimed with us. If patient is under 18, provide policy holder detailsFull NameDate of BirthTitleID Card/PassportGroup NameEmployee Name1. Patient Details 2. Claim DetailsReason for seeking medical adviceAmount being claimedIs this the first claim for this condition?Is this claim the result of an accident?Date patient first aware of symptomsIs this claimable from any other source ( another insurance company)?
I s thi s cl ai m the resul t of an acci dent? Date pati ent first aware of symptoms I s thi s cl ai mabl e f rom any other source ( i .e. another i nsurance company) ? Motor related Work related injury I f yes, pl ease gi v e detai l s Pr o vi de detai l s abo ut yo ur c l ai m .
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