HospitalClaimForm v2 amends for GDPR page

1 Please refer to your membership plan when claiming benefits. Please make sure you complete your member number as your claim could be Member s Personal DetailsMember number AddressTitlePostcodeSurnameTelephone numberDate of birth (DD/MM/YY) I want to be paperless, please send all my Health Shield membership information by email 2. Benefit Payment Direct to your Bank AccountBank/Building Society nameAccount numberSort code--3. Hospital ClaimsTitle Name of Hospital Patient's surname Patient's forename(s) Patient's hospital number (if known) The patient was admitted for the following treatment (Tick as applicable)Parental stayYes No If 'yes', please state dates DD/MM/YYDD/MM/YYHas the patient previously been admitted for this condition?

2 Yes No FOR OFFICE USE ONLYYou can use your member number or email address to check yourbenefit allowances and submit receipt-based claims online by visiting the Members' Area on our website (s)Personal EmailPlease enter your bank details below. If you have already provided these details then there is no need to fill them in again unless your account details have altered, or we hold more than one account on your policy. We no longer pay benefit by cheque. If this is a problem then please contact us on 01270 member must fill in section 3.

3 This must then be checked, signed and stamped at the hospital, registered treatment centre or , please enclose proof of your hospital stay by sending your discharge letter or discharge summary. Please allow 2 to 3 weeks when claiming these patientgiven anaestheticor sedation Maternity-relatedRespite CareInpatient Name of parent accompanying child overnightNo. of nights Dates: FromToAdmissionsDate admittedDate dischargedHas the patient been on home leave? Numberof nightsNumberof daysMedical conditionPLEASE REFER TO YOUR MEMBERSHIP PLAN WHEN CLAIMING MAKE SURE YOU COMPLETE YOUR MEMBER NUMBER AS YOUR CLAIM COULD BE A ND/OR COMPLETE THE APPROPRIATE BOXES WHERE APPLICABLE PLEASE PRINT THIS FORM AT 100% SCALE ON YOUR PRINTER SETTINGS SO IT PRINTS OVER 2 PAGES Official stamp of hospital, registered treatment centre or hospicePosition of authorised officialSignature of authorised officialDate (DD/MM/YY)4.

4 For Mater nity - Antenat al A ppointment and A doption Clai ms OnlyDate of scanOfficial stamp of Surgery or hospital (DD/MM/YY)How many weeks pregnant at scan datePatient's nameSignature of authorised official5. Member s A uthorisat ion and Signat ureYour signatureDate (DD/MM/YY) Fr audulent c lai ms Health Shiel d are committed t o p rev enting f inancial c rime and w e will r eport t o t he police al l i nstances o f f raud o r attempted f Shield Friendly Society Ltd. Electra Way, Crewe Business Park, Crewe, Cheshire, CW1 6 HSTelephone: 01270 588555 Fax: 01270 251366 Opening hours: to , Monday to FridayEmail: Website: Established in 1877.

5 Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation part of our on-going quality control programme, calls may be monitored or certify that the patient was admitted on these dates for the medical condition(s) detailed above Please print this form and sign in the box below before returning to Health Shield I declare that all the information included is accurate, true and complete to the best of my knowledge and belief. I agree that Health Shield can confirm the details with the healthcare provider.

6 I understand that Health Shield may end my membership if my claim is found to be would like to hear from you by email I would like to hear from you by telephone I would like to hear from you by SMS I would like to hear from you by postWe d love to keep you updated and send you more interesting content in the future. Please select your preferences below and if you would like to change your preferences at any point, you can do so on our website. Health Shield will always treat your personal information with the greatest care and never pass it on to other organisations for marketing purposes.

7 For more information on how we process your personal data please refer to our Privacy Policy or contact us for a paper copy. Please tick the boxes below to tell us how you would prefer to hear from us:This section must be completed by the Surgery or hospital if claiming maternity - antenatal. If making a claim for adoption of a child aged sixteen or younger please attach a copy of the adoption ease ret urn t oCl ai ms c hecklistPlease return this form, along with all necessary additional information and receipts to Health Shield. Have you signed and dated section 5?

8 Have you included your membership number?Have you attached the relevant receipts, certificates or papers?Has the hospital checked, stamped and signed section 3?Is your treatment date less than 12 months ago?Have you read the terms & conditions relevant to the benefit youare claiming?Health Shiel d Friendly Societ y L tdEl ec tra Way, Cr ewe Busines s Par k,Cr ewe, Ches hire CW1 6HS Have you completed section 2?