Healthcare 99
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Option A - Full Cover
Option B
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Option A - Full Cover
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Terms & Conditions
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Pre Approval Form PH1
Pre Approval of Claims
Reimbursement of Claims
Reimbursement Claim Form
Printable Forms
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Healthcare 99 Feedback
NZFFWS
Healthcare 99 Request for Pre-Approval of Treatment Costs: PH 01
*
Indicates required field
Name of Member
*
First
Last
Email
*
This section is about the patient information.
Name of Patient
*
First
Last
Patients Date of Birth
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Is this an ACC Claim
*
Yes - ACC claims are not covered. Refer to policy wordings for full details
No - Please proceed
This section is about your claim
information.
Diagnosis
*
Proposed Treatment
*
Name of Provider/ Specialist
*
Please upload you specialist report/GP referral
*
Max file size: 20MB
Estimated Cost
*
Please upload all quotes/ estimates
*
Max file size: 20MB
Name of Hospital/ Clinic
*
Date of Procedure
*
Privacy Statement
This document collects personal information about you so the New Zealand Firefighters Welfare Society can consider your claim.
The information is received and held by the New Zealand Firefighters Welfare Society, Private Bag 31999, Lower Hutt 5040.
You may request access to, and correction of, this information according to the provisions of the Privacy Act 2020.
I declare to the best of my knowledge the details given in this claim form are true.
I agree that the New Zealand Fire Fighters Welfare Society may give or obtain from appropriate individuals or organisations information relevant to evaluate and administer this claim.
With regard to any injury or illness, I hereby authorise any hospital, physician or other person who has attended me to furnish the New Zealand Firefighters Welfare Society, or its representatives, with any and all information with respect to any medical history, consultation, prescription or treatment and copies of all hospital or medical records.
I agree that an electronic version of this authorisation shall be considered as effective and valid as the original and that electronic invoices submitted are copies of the original invoices (please retain the original invoices in case we require them later).
By checking this box you agree to the privacy statement above.
*
I agree to the privacy statement and confirm it is true and correct
Submit
Healthcare 99
Join
Plans
Option A - Full Cover
Option B
Costs
Option A - Full Cover
Option B
Terms & Conditions
Claims
Pre Approval Form PH1
Pre Approval of Claims
Reimbursement of Claims
Reimbursement Claim Form
Printable Forms
FAQ
Contact Us
Healthcare 99 Feedback
NZFFWS