Pre-Authorise Treatment | William Russell

Instagram
This field is for validation purposes and should be left unchanged.
Which type of inpatient treatment are you requesting pre-authorisation for?
- Medical
- Maternity
- Cancer
- Mental Health
For Maternity we ask that you download and complete this form and email us via [email protected]
For Cancer we ask that you download and complete this form and email us via [email protected].
For Mental Health we ask that you download and complete this form and email us via [email protected]
Your personal details
Name*
First
Date of birth*
DD slash MM slash YYYY
Plan/policy number*
Customer/member ID*
Email address*
Telephone number*

Insurer information & declaration
Do you have any other health insurance cover?*
Name of insurer
Address of insurer
Policy number
Are you entitled any state-funded medical care?*
Are you entitled to benefits under any state-funded medical care scheme and/or do you hold a European Health Insurance Card (EHIC).
- Yes
- No
Please upload supporting documents
Drop files here or

Max. file size: 10 MB.
Declaration*
I declare that the information contained in this claim form is complete and accurate to the best of my knowledge and belief. I authorise any physician, medical doctor, health professional, or medical establishment that I have consulted, or who has treated me, to provide to William Russell and/or its authorised representative, with any and all information relating to my medical history.
- I agree
Your full name*

Your personal details