Benefit Wallet Claims Form

Section A - Member Details
Member Number
Date of Birth

DD
MM
YYYY
First Name
Surname
Home Telephone
Cellphone Number
Email Address
Date

DD
MM
YYYY
Postal Address
Street Address City State / Province / Region ZIP / Postal Code
Section B - Principal Member Details
Member Number
Date of Birth

DD
MM
YYYY
First Name
Surname
Relationship to Member
Diagnosis
Section C - Claims Detail (attach copies of all related claims)
Health Professional Date of Treatment Claimed Amount
Section D - Bank Details (For EFT Claim Refunds) (Attach proof of bank account details)
Name of Account Holder
Bank Name
Branch Code
Type of Account
- Cheque
- Transmission
- Savings
Account Number
Section E - Declaration
Signature
Date

DD
MM
YYYY
Section F - For Office Use Only
Assessor Name
Date Assessed

DD
MM
YYYY
Signature
Validator Name
Date Checked

DD
MM
YYYY
Signature

Health Professional	Date of Treatment	Claimed Amount