HealthCarePlus Online Claim Form
Please note this form is used for Primary Care plans only.
Unimed pays your claim reimbursement directly to your bank account, so...
If you would like to continue the form later, please use the "Save" button. You might see the pop-up notification for login/sign up, please choose "Skip Create an Account" and then enter your email address to continue later.
Please note that the upload size limit is 20 MB. If you would like to attach a lot of photos at once, we strongly recommend to convert them to PDF files before uploading to our system.
If you would like to continue the form later, please use the "Save" button. You might see the popup notification for login/sign up, please choose "Skip Create an Account" and then enter your email address to continue later.
PRIVACY ACT Pursuant to the Privacy Act 2020 the following is brought to your attention:
(a) This claim form and any supporting documents collect personal information about you and is collected to effect the claim you make.
(b) In assessing and processing your claim UniMed may need to collect, disclose or use your personal information, including the collection of information from third party health service providers.
(c) You are required to provide all information that is material to the claim. If you fail to provide this information or provide inaccurate information it may result in your claim being delayed or declined or Membership voided.
(d) Each person in this claim form authorises UniMed to obtain from any party or organisation (including health care providers) any information reasonably required to evaluate and investigate this claim, and each person named in this claim form authorises that party or organisation to disclose such information to UniMed.
(e) In completing and submitting this form you consent to the collection, disclosure and use of your information in accordance with the Privacy Act 2020, the Health Information Privacy Code and the Privacy Statement contained in the UniMed/HealthCarePlus Conditions of Membership. You also consent to the collection, disclosure and use of your information for the purposes of the Integrity Register.
OFFICE USE ONLY
After submitting the form, DO NOT close the window immediately, please wait until you see the "thank-you" page.
HealthCarePlus is administered and underwritten by Union Medical Benefits Society Ltd (UniMed). Any cover issued in response to this application is subject to the terms and conditions contained in the relevant policy documentation and UniMed/HealthCarePlus Conditions of Membership.
UniMed, PO Box 1721, Christchurch 8140. Level 3, 165 Gloucester Street, Christchurch 8011. P 03 365 4048 FP 0800 600 666 F 03 365 4066 E firstname.lastname@example.org W www.unimed.co.nz