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.