Day-to-Day Medical Expenses

Claim Form

Section 1: Your contact details

Please complete all the boxes using blue or black ink.
Policy Holder’s/Member’s Name and Address Policy Number:

Is this the Policy Holder’s permanent address? Yes No

1. Home Contact Number:

2. Mobile Contact Number:

By providing your mobile number you agree to receive SMS text
Email Address: updates on the status of this claim.

Section 2: Your payment details

As payment will be sent to your bank please complete the details below:

Current Account Name:

Current Account Number: Branch Sort Code:

Bank/Building Society Name and Address:

Section 3: Persons covered on your policy

Please complete the first name, surname and date of birth for each person for whom you are claiming.
First Name Surname Date of Birth (DD MM YY)

D D MM Y Y
D D MM Y Y
D D MM Y Y
D D MM Y Y
D D MM Y Y
D D MM Y Y

Section 4: Declaration
I declare that the expenses, details of which are submitted with this form, were incurred by me and/or members covered under my policy in respect
of services received during the insurance year. I declare that to the best of my knowledge the foregoing statements are true in every respect.

X Policy Holder’s/Member’s Signature D D MM Y Y

(You must sign here) ––––––––––––––––––––––––––––––––––––– Date:

Data Protection Notice - The information you provide becomes part of the personal data held by Vhi Healthcare and is automated. It is used for the
payment of claims and for the provision and administration of health insurance products and related services. Full details of Vhi Healthcare’s use of
DDMENPOP7 MARCH 2010

personal data appear in the public register held by the Data Protection Commissioner.
SV
 Section 5: Receipt details
Receipt Type Number of Receipts Receipt Type Number of Receipts
GP Visits Consultant Visits
Dental Visits Consultant Pathologist Fees
Physiotherapy Consultant Radiologist Fees
Complementary Therapies Pathology Technical Charges
Alternative Therapies Radiology Technical Charges
A&E Levy Pre- & Post-Natal Care
Optical (Eye Tests, Glasses/Lenses) Clinical Psychologist Visits
Screening Dean Clinic Mental Health Assessment
Hearing Tests Dean Clinic Mental Health Therapy
Prescription Costs Foetal Screening
Travel Vaccination Ante-Natal Day Course
Baby Massage Classes Breastfeeding Consultations
Consultant Paediatrician Voice Coaching
Child Counselling
The benefits listed above are not available on all plans.
The benefit payable for each treatment type is outlined in your Table of Benefits sent to you at renewal and in accordance with the
Rules - Terms and Conditions available at www.vhi.ie or on request.
Please note that an annual excess will be applied to each member’s claim. The amount of the excess deducted will depend on the cover
held by the member at the renewal date prior to treatment.

Section 6: Treatment types

GP Visits Charges incurred for visits to a medical practitioner with a current full Child Counselling Charges incurred for visits by a member who is under the age of 16 and
registration with the Irish Medical Council, who holds a primary medical has been referred by a GP or Consultant to a Clinical Psychologist registered
qualification. with the Psychological Society of Ireland.
Dental Visits Charges incurred for visits to a Dental Practitioner with a current full Consultant Visits Charges incurred for visits to a Consultant who has a current full registration
registration with the Irish Dental Council, who holds a primary dental with the Irish Medical Council and fulfils the requirements as defined in your
qualification. He/she is community based and provides dental care. Rules - Terms and Conditions.
Physiotherapy Charges incurred for visits to a Physiotherapist as part of a once-off or Consultant Charges incurred for Consultant Pathologist fees.
regular treatment arising from a medical condition. The Physiotherapist Pathologist Fees
must be a member of the Irish Society of Chartered Physiotherapists.
Complementary Where treatment is provided by a Dietician, Occupational Therapist, Consultant Charges incurred for Consultant Radiologist fees.
Therapies Podiatrist/Chiropodist, Speech Therapist and/or Clinical Psychologist as Radiologist Fees
defined in your Rules - Terms and Conditions.
Alternative Therapies Where treatment is provided by an Acupuncturist, Chiropractor, Osteopath, Pathology Technical Charges incurred for pathology tests other than consultant pathology fees
Reflexologist or Physical Therapist as defined in your Rules - Terms and Charges in an approved Out-patient Centre.
Conditions.
A&E Levy Charges incurred from visits to an Accident and Emergency Department in Radiology Technical Charges incurred for radiology tests other than consultant radiology fees in
respect of the out-patient levy. Charges an approved Out-patient Centre. Please note MRI claims should be
submitted on a different claim form that is available at www.vhi.ie
Optical (Eye Tests, Charges incurred for eye tests and/or prescription spectacles and contact Pre- & Post-Natal Pre- and post-natal care services carried out by a GP, Consultant or Midwife
Glasses/Lenses) lenses. Eye tests must be carried out by an Optometrist registered with Care (as defined in your Rules - Terms and Conditions) in the year of the birth.
the Opticians Board or by an Ophthalmic Surgeon or Ophthalmic Physician
registered with Vhi Healthcare.

Screening Charges incurred for specified medical tests or investigations, which are Clinical Psychologist Charges incurred for clinical psychology visits to a Clinical Psychologist who
designed to identify certain characteristics, or the presence or susceptibility Visits is a member of the Psychological Society of Ireland.
to a particular disease or condition.
Dean Clinic Mental Charges incurred for the cost of a mental health assessment in an approved
Health Assessment Dean Clinic centre.

Hearing Tests Charges incurred for a hearing test carried out by an Audiologist who is Dean Clinic Mental Charges incurred for the cost of a mental health therapy session in an
registered with the Irish Society of Audiology or the Irish Society of Hearing Health Therapy approved Dean Clinic centre.
Aid Audiologists.

Travel Vaccination Charges incurred for vaccinations administered by a GP or Consultant in Foetal Screening Charges incurred for chorionic villus sampling, amniocentesis and
preparation for travel to certain countries. cordocentesis.

Prescription Costs Charges incurred for drugs or medicines prescribed by a GP, Consultant or Ante-Natal Day Charges incurred by members for attending an approved ante-natal course
Dental Practitioner. Course over a single day to help them prepare for the birth of their child. Courses
must be given by a qualified Midwife as defined in your Rules - Terms and
Conditions.
Baby Massage Charges incurred for attending baby massage classes which are carried out Breastfeeding Charges incurred for a member’s consultation session with a qualified
Classes by members of the International Association of Infant Massage within one Consultations Midwife (as defined in your Rules - Terms and Conditions) within one year of
year of the birth of your child. the birth of your child.
Consultant Charges incurred for the first visit of your child to a Consultant Paediatrician Voice Coaching Charges incurred for voice coaching visits to a Voice Coach who is a member
Paediatrician within one year of the birth. of the Irish Voice Association.
Guidelines to Completing Claim Form - PLEASE REMOVE BEFORE SUBMISSION OF YOUR CLAIM
Section 1 - Your contact details
Please complete your personal contact details in full. If you have changed address, please complete your new details
and we will update our records.

Section 2 - Your payment details

To ensure prompt payment of your claim, we can arrange to make payment directly into your bank account, providing
you complete 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.

Section 3 - Persons for whom you are claiming

Please complete this section with the name and date of birth of the person/persons for whom you are claiming.

Section 4 - Declaration
Please ensure that you sign and date your claim form. Incomplete claim forms will be returned, so take a moment to
ensure that all sections have been fully completed.

Section 5 - Receipt details

Please review the list of receipt types and if applicable complete the number of receipts in the box provided.

Section 6 - Treatment types

This section lists and provides you with a brief explanation of the day-to-day medical expenses covered by our range of
plans. The cover you have depends on the plan you hold. If you would like information on the benefit provided by your
plan please refer to your Table of Benefits and Rules - Terms and Conditions. You can download a copy of the latest
Rules - Terms and Conditions on www.vhi.ie/downloads or request a copy from us.

Benefits payable are those applicable to the renewal year for which you are claiming.
We require original receipts to process your claim and unfortunately we do not return originals. Therefore, we advise
that you keep a copy of your receipts. Your local tax office will accept your Vhi Healthcare benefit statement, instead
of your original receipts if you are making a Med1 claim.

Checklist
✓ Sign and date your claim form.
✓ Complete each section of the claim form in full.
✓ Attach original receipts.

Please return the completed form together with your receipts to:
Vhi Healthcare
PO Box 11530
Dublin 18