Language
English (UK)
Polski
Treatment abroad refund application.
Make sure you have filled in all fields. You cannot claim a refund for planned treatment that was not provided as a part of emergency or necessary healthcare.
Who is filling this application?
*
This is my claim for a refund
I'm making a claim on behalf of the person named below
Name of the patient
*
First name
Last name
Date of birth of the patient
*
/
Day
/
Month
Year
Address
*
0/50
Postcode
*
Phone Number
*
Email
*
example@example.com
NHS number
*
NHS number is a 10-digit number, like 485 777 3456
National Insurance number
*
Example: QQ 123456 C (if patient dose not have the number write "No NIN"
What is your Nationality?
UK/Irish national
EU national
Swiss national
Dual national (please specify the nationalities held)
Norwegian, Icelandic or Liechtenstein national
Other
Dual nationalities
Please specify nationality held
Please specify nationality held by you
Did you receive your tretment in Switzerland?
Yes
No
Back
Next
Travel details
*
I confirm it was a temporary visit (includes holidays, visiting family or short business trips)
Was your treatment arranged prior to leaving the UK?
*
Yes
No
When did you leave the UK?
*
/
Day
/
Month
Year
When did you arrive back to the UK?
*
/
Day
/
Month
Year
Have you paid for medical treatment?
*
Yes
No
Did you present a valid UK EHIC or UK GHIC at the point of treatment?
Yes
No
Was your UK EHIC or UK GHIC accepted?
Yes
No
If your UK EHIC or UK GHIC was not accepted, what reason was provided for this?
What currency is the invoice in?
*
Please Select
EUR
PLN
CZK
BGN
HRK
DKK
HUF
ISK
CHF
NOK
RON
SEK
OTHER
What is the total cost of the treatment you wish to claim? The amount should be in the currency you paid.
*
The amount should be in the currency you paid in.
Please add proofs of payment (invoice/receipt).
Browse Files
Drag and drop files here
Choose a file
You can upload up to 5 files pdf, zip, jpg, jpeg, png up to 15 MB in total.
Cancel
of
Back
Next
Country of treatment
*
Date of admission
*
/
Day
/
Month
Year
Date of discharged
*
/
Day
/
Month
Year
Please provide a brief description of the nature of the illness, accident or injury
*
0/200
Please provide details of what treatment was received
*
0/200
Name of doctor or establishment that provided the treatment
*
To the best of my knowledge, the doctor or establishment that provides the treatment is run by the state or contracts to provide state-funded treatment.
*
Address of treatment facility
*
0/50
Upload medical report
Browse Files
Drag and drop files here
Choose a file
You can upload up to 5 files pdf, zip, jpg, jpeg, png up to 15 MB in total.
Cancel
of
Back
Next
Warning: False information may lead to civil or criminal action. If you are signing on behalf of somebody else, you will be responsible for the information provided.
Type a question
I acknowledge that I will lose the right to cancel the order within the statutory period of 14 working days as we will commence the delivery of an order immediately and before this statutory period ends. Therefore the services will have deemed to have been provided and you will lose the right to cancel your order. I acknowledge that I have British, EU, EEA or Swiss nationality and that all persons to be specified in this application are UK residents. The information that I give on this form is correct and complete to the best of my knowledge and I have read and accept the terms of the privacy policy.
I confirm that the patient mention in this application does not have healthcare cover from another country besides the UK (such as having an S1, E121, E106, or E109).
I confirm that patient lives in the UK.
I declare that the information given on this form and the supporting documents are correct and I understand that if I knowingly provide false information, I may be liable to prosecution and/or civil proceedings. I will inform Overseas Healthcare Services immediately if there are any changes which could impact my claim. I understand that my information may be disclosed to other public bodies and authorities in the country providing my treatment in order to process this claim, to provide verification or to make payment. I understand that my information may be disclosed to the NHS Counter Fraud Authority and the Department of Health and Social Care Anti Fraud Unit for the purpose of the prevention, detection, investigation and prosecution of fraud and any other unlawful activity affecting the NHS.
My Signature
*
Signature
*
Name of person who filled in this form: (in capitals)
*
Address of person who filled in this form
*
0/50
Contact telephone number
*
-
Country code
Phone Number
EHIC UK
Back
Next
Medrefund LTD service is now offered on
prev
next
( X )
GBP
You will be redirected to payment page.
Submit
Should be Empty: