Overseas Student

Health Cover

Claim Form
Please complete both sides of this form in CAPITAL LETTERS. Email your completed form to oshcclaims@allianz-assistance.com.au with the
required documents (refer to section 5 for details) OR submit a claim via the My OSHC Assistant App
Section 1 - Policy Holder Details:

Policy Number (must be provided): WEB43482739AIOTE

Title: Dr/Mr/Mrs/Miss/Ms MR Family Name (surname): Singh
Given Name (first name): Akashdeep Other name/s:

Date of Birth: 30/08/2001 Gender/ MALE

Australian Home Address
(Name and street number):
11, ORALLO AVENUE
Suburb: BLACKTOWN State: NSW Postcode: 2148
Mobile Number: 0492848358 Alternative number (optional): 0492848358
Email Address: preet98773@gmail.com
Nationality: INDIAN Passport Number: T4925271
Do you have any other type of health insurance (in home country, Medicare
etc.)? If YES, please provide the name of the insurer and your policy number.
Section 2 - Details of expenses claimed:
Patient’s first name Provider of service Date you visited Amount on Have you already
e.g. Dr Jones doctor or received invoice paid for this service?
treatment? Please answer Yes or
No
1.AKASHDEEP SINGH DR. RADWAN BARBANDI 15 / 07 $80.00 Yes No
/2020 INVOICE:
1107645
2.AKASHDEEP SINGH DR. KYAW-MYINT MALIA 29 / $40.00 Yes No
07 /2020 INVOICE:
26832KM
3.AKASHDEEP SINGH DR. DONA BISWAS 07 / 07 $402.75 Yes No
/2020 INVOICE:
223414891
4. / / Yes No

5. / / Yes No

If you are making a claim for a dependant, you must ensure your dependant’s details are registered on your policy otherwise we will not be able to
process your claim. You can do this by logging into the student portal (https://allianzassistancehealth.com.au/en/auth) and selecting “Check and
update your details”
Section 3 - Payment to Australian Bank Account by Electronic Funds Transfer
Please provide bank account details to ensure prompt payment (only complete if you have already paid the account and have attached copies of
tax invoices and receipts). If correct bank details are not provided, a cheque will be sent to your Australian home address as specified in
section 1 of this form.
Name of financial institution: COMMONWEALTH BANK

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 Name of account holder: SUKHPREET KAUR
BSB number: 062-948
Account number: 2328-7598
Section 4 - This section must be completed for all claims
Are the expenses claimed for a medical assessment, x-ray or blood tests required for the renewal or issue of your student visa? Yes No

Was your illness, injury or condition caused or contributed to by someone else e.g. car accident, workplace accident/incident or by another
person’s negligent acts of omissions? Yes No
If yes, please download and complete the Accident Information Form from the Help Centre of the website
https://allianzassistancehealth.com.au/en/student-visa-oshc/help-centre/
Why did you need to see a doctor or receive medical
MEDICAL CERTIFICATE AND
treatment?
PSYCHAIRIST REPORT

Did you go to hospital in an ambulance? Yes No

If Yes, please give the reason why and details of who called the ambulance.

Section 5 - Required Documentation

In order to process your claim we need you to send us the following documents:
• Itemised invoice with details of treatment provided and a breakdown of costs
• Proof of payment (where this is not provided, we will pay the medical provider directly)
We may need you to send us additional documents depending on the nature of your claim or your policy circumstances. Please read the section
below to understand what additional documents may be needed.
If your claim is within 12 months of your policy start date and is for treatment in hospital or treatment other than a GP visit, please
download and complete a Medical certificate from our website: https://allianzassistancehealth.com.au/en/student-visa-oshc/help-centre/
If you have transferred your cover to Allianz Global Assistance within the last 12 months, please send us a copy of your Clearance Certificate
from your previous insurer.
If your claim is related to an injury or accident, please download and complete an Accident Information Form from our website
https://allianzassistancehealth.com.au/en/student-visa-oshc/help-centre/
Allianz Global Assistance will endeavour to process your claim within 10 working days of receiving a completed claim form and all required
documentation.

To assess claims, AGA may request the original documentation and any further additional documentation within 90 days after claim submission
due to auditing purposes.
Section 6 - Declaration
I declare that all statements and particulars contained on this claim form are true and correct.
I authorise Allianz Global Assistance to contact the hospital, an insurer or insurance reference bureau, or provider of any service for further
clarification of details relating to this or any other claims I have made.
Signature: AKASHDEEP

Date: 10 / 11 /2020

Section 7 - Authorisation
If you wish to provide approval for someone else to speak or act on your behalf about this claim you must complete the following
details (otherwise we will not be able to give any information about your claim to any other person).
I/we, authorise (Name) SUKHPREET KAUR

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 Of (Address) 11 ORALLO AVENUE, BLACKTOWN
Mobile: 0492848358
To act on our behalf in respect of this claim and to be provided with information relating to this claim.

Please return completed form and all required documentation to:

You can send us your scanned claim form and documents by email to oshcclaims@allianz-
assistance.com.au

You can post us your claim form and documents to the following address:
Allianz Global Assistance OSHC
OSHC Claims
Locked Bag 3001
Toowong QLD 4066
Australia

Section 8 - Before you claim

Waiting Periods
The OSHC policy includes waiting periods for the treatment of pre-existing conditions. This means that if you received treatment for a pre-
existing condition during the relevant waiting period, you cannot claim for the costs and you will need to pay the entire amount. A waiting period
is calculated from either the date you arrived in Australia or the date your visa was granted, whichever is the later date. See your policy
document for further details in relation to waiting periods (https://allianzassistancehealth.com.au/en/policy-wording-documents).

Section 9 - Privacy Notice

The personal information that you provide is collected for the purpose of issuing you with OSHC, determining any claims you may make on this
policy (including complying with regulatory requirements in relation to OSHC) and for ancillary purposes as set out in our Privacy Policy.
By providing your personal information, you agree and consent to our Privacy Policy which is available on request or view it on the web at
http://www.allianz-assistance.com.au/privacy-and-security/.
For example, in the course of providing our services, assessing claims, and carrying out our business activities, your personal information
(including personal information of others named on your Certificate of Insurance) can be disclosed to education providers, health fund
providers, underwriters and insurers including People care Health Limited, marketing and service provider intermediaries, government
departments including the Department of Home Affairs, medical practitioners, hospitals, and other medical service providers, claims assessors,
investigators, our related and group companies including Allianz , and other international assistance and service providers with whom we
engage. To provide our services, we may transfer your personal information overseas. You also agree to allow us to disclose details of your OSHC
and other personal information received from any healthcare provider who provides you with treatment for the purposes set out in this Privacy
Notice. We do not disclose your medical information for marketing purposes.
If you would like to gain access to or correct any of your personal information, please contact Allianz Global Assistance at
personalinformation@allianz-assistance.com.au If you do not agree with our Privacy Policy, you must inform us as we may not be able to
provide our services to you including assessment of your claim.
Allianz Global Assistance Overseas Student Health Cover policies are authorised under a Deed entered into between People care Health Limited and the Australian
Government through the Department of Health. Allianz Global Assistance OSHC is managed by AWP Australia Pty Ltd ABN 52 097 227 177 trading as Allianz Global
Assistance. People care Health Limited ABN 95 087 648 753, a private health insurer under the Private Health Insurance Act 2007 (Cth) is the underwriter of Allianz
Global Assistance Overseas Student Health Cover policies.