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Which policy are you claiming on?*

Are you the main policyholder?*

Policyholder's full name:*

What is your relation to the policyholder?*

Your first name*

Your last name*

Contact telephone number

Email address*

Membership number

Are you the patient?

Patient's full name:*

Patient's DOB:*

Is the patient over 16?*

Please tick that you have permission from the patient to discuss their claim with us. If you don't have permission, you cannot proceed. Where we state 'you/your' throughout this form, we mean the patient. I confirm

Please tick that you consent for AXA Health to process any data received in relation to this claim. This will include any invoices and medical information. This information will be processed to make payment and determine claim eligibility.* I confirm

Do you want to receive payment into your account?*

We'll use the bank account details we have unless you tell us otherwise. If we don’t hold any, we'll send a cheque.

Payments usually take 4 working days once processed. Cheques will take 7-10 working days.

What is the total amount you're claiming for?

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You can find independent information about the quality and cost of private treatment available from doctors and hospitals by looking at the Private Healthcare Information Network website at www.phin.org.uk.

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