Benefit claim form Please return to - WHA Direct

1 Benefit claim formSubject to the Benefit and General Conditions currently in forceW43P-2/16-1 Name, address and postcode of subscriberMembership number Date of birth Marital status ( Please tick one) Married Widowed Single Divorced Legally separated Civil partnershipDaytime telephone numberPlease return to:WHA Direct , 60 Newport Road, Cardiff, CF24 0YG. Tel: 029 2048 5461 Separate claim forms are required for each claim . No more than one claim per form Please . Please indicate who you are claiming Subscriber B Subscriber's spouse Name AgeC Additional member Name AgeRelationship to subscriberMarital statusDate of birth Subscriber's declarationI declare that the information given on this form is correct and true and that any fees stated have been incurred and paid either by myself or the patient and are not eligible for reimbursement from any other source.

2 Any attempt to defraud WHA will result in legal 1 Hospital inpatientTo be certified on discharge from hospital or when the patient has been in hospital for 42 daysPatient s name: Forename(s) Surname Date of birth Medical classification Accident Emergency Other ( Please state)First inpatient admissionName of hospital (official stamp)Second inpatient admissionName of hospital (official stamp)Admitted Discharged or still in hospital Signature and position of hospital officerDate Admitted Discharged or still in hospital Signature and position of hospital officerDate DDMMYYDDMMYYDDMMYYDDMMYYName of hospital (official stamp)Date Full nameQualificationsSignatureDate Amount paid Amount paid in words (pounds only)

3 PoundsPractitioner s official stamp/business cardSection 2 Hospital OutpatientSection 3 Personal AccidentPersonal accident Benefit is not applicable to Personal 7 and Partners 14 send me a Personal Accident claim form , if eligible ( Please tick box) Details of injury sufferedSection 4 CounsellingTo be completed by the Practitioner. The Practitioner s receipt must be of patientDescription of conditionDates of appointments from The PRACTITIONER S CERTIFICATION section must be completed and 5 OpticalTo be completed by the Optician. The Optician s receipt must be of patientDetails/description of lensesDate of supplyPrescription/test dateValue of vouchers towards cost (if any)The PRACTITIONER S CERTIFICATION section must be completed and 6 DentalTo be completed by the Dentist.

4 The Dentist s receipt must be of patientDetails/description of treatment Dates of treatment from The PRACTITIONER S CERTIFICATION section must be completed and 7 Alternative TherapiesFor Acupuncture, Alexander Technique, Bowen Therapy and Sports Therapy/Massage. To be completed by the Practitioner. The Practitioner s receipt must be is qualified to provide the following treatment Patient s nameDescription of condition treatedDates of treatment fromPractitioner s qualification/registration Number of treatments Cost per treatment The PRACTITIONER S CERTIFICATION section must be completed and stampedSection 8 Physiotherapy, Osteopathy,Chiropractic & Chiropody/PodiatryTo be completed by the Practitioner.

5 The Practitioner s receipt must be s profession ( Please tick as appropriate) Physiotherapist Osteopath Chiropractor Chiropodist/Podiatrist HCPC/GOC/GCC NumberPatient s nameDescription of condition treated Dates of treatment fromNumber of treatments Cost per treatment The PRACTITIONER S CERTIFICATION section must be completed and stampedSection 9 Specialist ConsultationTo be completed by the Consultant. The Consultant s receipt must be of patientCondition which necessitated the consultationThe PRACTITIONER S CERTIFICATION section must be completed and S CERTIFICATIONA ttendance dates (minimum of three)First Second Third Signature and position of hospital officerDDMMYYDDMMYYDDMMYYtoW43P-2/16-1to toto