Submit your claim online
This form should be completed only if you’ve paid for treatment and would like to claim back the eligible costs. If the amount of your claim exceeds US$500 (or equivalent in another currency) please ask your physician to complete section B of the claim form which can be found here. This will then need to be uploaded with this form or emailed to us later at firstname.lastname@example.org.
Please complete the information requested and include supporting information via the document upload function. All fields marked with an * denote required fields.