Fillable Printable Doctor Receipt Form
Fillable Printable Doctor Receipt Form
Doctor Receipt Form
Guidelines to making your claim
• Claim form to be signed by main member or policyholder
• Please note that out-patient receipts will not be returned following assessment.
• Check that original out-patient receipts are enclosed (photocopies, cash register receipts, visa receipts etc. are not acceptable).
• Please ensure that all receipts include the name of the patient, the cost incurred and the date of the visit.
• The Revenue Commissioners will now accept your Statement of Claim (which we will send to you when your claim has been assessed) as evidence of medical
expenses incurred.
• Claims should be made at renewal date and only for out-patient costs incurred within the previous membership year.
• If your scheme has an annual excess, this excess will be applied to your claim. The amount of the excess deducted will depend on your scheme.
• If you have not already provided your bank account details for your claims to be paid directly into your account, please complete Section 8 which requires the
policyholder’s signature.
Using this claim form
This claim form has been designed to help you make a claim from laya healthcare for out-patient expenses.
Important note
For a full list of the out-patient benefits available on your scheme please visit the “How To Claim” section of our website, www.laya healthcare.ie or contact
us on 1890 700 890 or Cork 021 202 2000.
3 MRI section (to be completed by Consultant in overall charge of the patient)
Date of MRI:
Reason for referral:
MRI centre:
MRI procedure name(s) and code(s):
Name of GP/Consultant who referred you for the MRI: Consultant code:
Date: Day
Month Year
1 Member’s details
Membership no:
Title: Surname: Forenames:
Date of birth: Day
Month
Year
Telephone:
Correspondence address:
Email:
2 Dependants’ details for out-patient expenses
Name: Relationship to main member:
4 Accidents section (please complete in all cases involving injury)
Description and date of accident/injury: Day Month Year
Are the expenses recoverable from another source? Yes No
If yes, are you claiming these expenses through: Solicitor: Yes No or Personal Injuries Assessment Board: Yes No
If either of the above are selected, please state the name, address and policy details:
I declare that laya healthcare may contact my solicitor in order to ensure that any monies payable from a third party, as a result of an accident or an injury, are
repayable to laya healthcare to offset against any claims we pay:
Signed (insured member if over 16) Signed (subscriber)
Out-patient Claim Form
8 Your payment details
To ensure prompt payment of your claim, we can
arrange to make payment directly, where possible, into
your bank account.
If you currently pay your subscriptions by Direct Debit
and would like to have your claims paid, where possible,
directly to this account please tick the box.
If you have already provided your bank account details
for your claims to be paid directly into your account, you
do not need to resubmit this information.
Alternatively please complete the mandate with your
bank account details. If you do not provide these details
or if you provide us with incorrect bank details we will
pay you by cheque.
Name(s) of
account
holder(s):
IBAN:
BIC:
Please write the full name and address of your bank or building society.
Policyholder’s signature(s):
Date: Day
Month Year
I/we will inform laya healthcare if I/we wish to cancel the existing instruction for future claims payment.
Data Protection Act 1988 AND 2003
The information you provide will be used to manage the administration of your policy and is held in accordance with the Data Protection Acts 1988 and 2003 (as amended). We may
need to collect sensitive information (such as medical information) about you and others named on the insurance policy. By providing this information you will be agreeing to us or
our agents or other insurers processing that information for the purpose outlined above. In the event that your treatment has involved another person, or if their details are likely to
be documented in your Medical Notes/File, then their express consent should be acquired in advance of sharing sensitive data. Medical information will be kept confidential and may
be disclosed, on a strictly confidential basis to those involved with your treatment or care or their health professional agents. Information may also be shared with other insurers,
either directly or through people acting for the insurer such as Investigators and where we are entitled to do so under the Data Protection Acts. However, anonymised data – that is,
information which does not identify an individual – may be used by laya healthcare, or disclosed to others, for research or statistical purposes. Access to non-medical information
may be granted by laya healthcare to others on a strictly confidential basis in the course of and for the purpose of the efficient administration of laya healthcare (for example in
connection with audit, systems development, managing and improving our services). You have a right to apply for a copy of the information held by us about you (for which a small
charge, not exceeding €6.35, may apply) and you have a right to have any inaccuracies in your information corrected. Please send your request in writing to the Information Protection
Manager, at laya healthcare, Eastgate Road, Eastgate Business Park, Little Island, Co Cork.
LH-OutCF-008-10/15
Laya Healthcare Limited trading as Laya Healthcare
is regulated by the Central Bank of Ireland.
Claims should be sent to:
Laya healthcare, PO Box 12679, Dublin 15
6 Emergency dental section
Date and place of injury: Day Month Year
Description of accident/injury:
5 V.A.C Therapy
Date of hospital admittance relating to your V.A.C therapy: Day Month Year
Please include your referral letter from your Consultant.
Hospital Name:
Consultant’s
Name:
Consultant
Code:
Day
Month Year
To be completed by dentist
providing treatment
Date: Description of work carried out: Cost:
Date treatment
commenced:
Treatment dates:
Date treatment completed:
Signature and stamp of dentist
7 Receipt details
Treatment type: Number of receipts: Total cost of receipts: Treatment type: Number of receipts: Total cost of receipts:
9 Declaration and consent
I declare that the expenses detailed on this form were incurred by me and/or my dependants covered under my membership in respect of services received
during the subscription year, on the recommendation of registered medical practitioners. I declare that, to the best of my knowledge, the foregoing statements
are true in every respect.
Policyholder’s signature
(a parent or guardian if patient is under 16)
Date:
Note: Payment and Explanation of Benefits will be issued to the policyholder.
