Healthcare 99 Request for Pre-Approval of Treatment Costs: PH 01
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    This section is about the patient information.
    This section is about your claim information.
    Max file size: 20MB
    Max file size: 20MB
    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).