HealthCarePlus Claim form

HealthCarePlus Online Claim Form

Please note this form is used for Primary Care plans only.
1. Member Details

This (*) is a required field and must be completed in all cases. To move between fields, please use the TAB key.
Full Name *

First Name Last Name
Membership Number *
Address *
Email *
Phone Number
Unimed pays your claim reimbursement directly to your bank account, so...
- If you have already provided Unimed with your bank account number, select "Use my current bank details".
- Or If you pay by payroll deduction or your bank account has changed please select "Add or Update my bank details"
My bank account details *

Use my current bank details Add or update my bank details

NAMES AND DATES OF BIRTH OF PEOPLE FOR WHOM REIMBURSEMENT IS BEING CLAIMED: *

Name

Date of Birth

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.

2. Details of all claims

This (*) is a required field and must be completed in all cases. To move between fields, please use the TAB key.
IMPORTANT: specialist fees/tests/xrays are to lead on to an operation: *

YES NO

Note: Full detail of nature of illness or treatment received must be stated. Receipts in order of family member please. *

DATE OF VISIT (DD.MM.YY)

NAME OF PATIENT (In capital please)

NAME OF DOCTOR /PRACTITIONER

Nature of illness/treatment received

AMOUNT PAID

OFFICE USE ONLY

DATE OF VISIT (DD.MM.YY)

NAME OF PATIENT

NAME OF DOCTOR/
PRACTITIONER

Nature of illness/treatment received

AMOUNT PAID

OFFICE USE ONLY

End Collapse
Claim Amount - table 1
Claim Amount - table 2
Total Claim Amount
Upload Receipts (Total Max Upload size is 20MB) *

To upload multiple files, hold down the Ctrl key and click any file(s) you would like to upload and press OPEN.
Cancel of
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.

1. Member Details