Cash Plan Claim form D D M M Y Y D D M M Y Y. Your membership number. A. Your personal details

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1 Cash Plan Claim form You can now submit cash plan claims to us securely online, at: bupa.co.uk/cash-plan-claims If you d prefer to submit this claim form by post, then before sending you should check your table of cover for the benefits that you re eligible to claim for. Please make sure that you ve completed relevant sections of this form and that you ve included copies of receipts. We will be unable to process your claim without this information. You should keep your original receipts in a safe place. You should send all completed claim forms to us at: Bupa, Anchorage Quay, Salford Quays, Salford M50 3XL. If you have any queries when completing this form then please call our Member Services Team on *. Please complete this form in BLOCK CAPITALS and use a black pen. Your membership number A. Your personal details Please tell us about yourself here. Mr/Mrs/Miss/Ms/Other (please circle or list title if other) First name(s) Address Postcode Telephone number Mobile number address Date of birth Claimant s personal details (If the claimant is not the main member) Mr/Mrs/Miss/Ms/Other (please circle or list title if other) First name(s) Address Postcode Telephone number Mobile number Date of birth Is this claim as a result of a third-party accident or injury? Yes No *We may record or monitor our calls. Lines are open from 8am to 6pm on Monday to Friday and 8am to 1pm on Saturday.

2 B. Payment details You can receive payments for claim settlement direct to your chosen bank or building society account, helping to make settling your claim safer and more timely. This simply means that instead of posting a cheque to you we can automatically pay your claim by BACS (Bank Automated Clearing System). BACS normally enables a cleared payment to reach your Bank account three working days after Bupa has processed the claim for payment. Payments into a Building Society account may take a day longer. Written advice of payment will be posted to you. Please let us know if you would like to receive payment via BACS or cheque. Cheque BACS If you have opted for payment by BACS please provide the following details. Account holder name Account number Sort code Please be aware that the quickest method of receiving funds is by BACS payment as these are normally received within three working days of the claim being finalised. We are able to pay by cheque but this may cause delays in you receiving reimbursement of eligible claims. As the main member under the scheme, I hereby authorise Bupa to direct payment to the bank account specified above. Signature Date C. Claim details Please tick the appropriate box for the benefit that you are claiming for, and fill in the appropriate section. Please refer to your table of cover: this shows the benefits on your scheme, including the limits that apply or any variations to those benefits. Benefit description Allergy testing Alternative therapies Acupressure, Aromatherapy massages, Audiology tests, Bowen and Alexander techniques, Chair massage, Cognitive Behavioural Therapy (CBT), Electrocardiogram (ECG), Hypnotherapy, Indian Head Massage, Kinesiology, Lung Function tests, MRI scans, Nutritional therapy, Pathology tests, Reiki, Shiatsu, Speech therapy, Sports and Remedial massage. Chiropody/Podiatry Consultations, diagnostic tests and scans Dental and dental injury Please fill in sections D, F and I (where applicable) Flu jabs Funeral grant Please fill in sections D, G and I Health assessment/screening Home help Hospital stay (in-patient, day-case) Please fill in sections H and I Maternity and adoption Please fill in sections E and I Optical Prescriptions Recuperation at home Therapies (physiotherapy, osteopathy, chiropractic, acupuncture, homoeopathy, reflexology) For office use only Date received Claim ID

3 D. Receipted claim A copy of the original itemised receipt must accompany all claims and you should keep the original in a safe place. Your receipt should bear the name and address of the practitioner alongside the patient where applicable. Benefits are paid as a percentage of the receipted amount up to your cash plan s annual benefit limit. Amount paid Receipt date Receipt amount in words Pounds Pence E. Maternity or adoption Please submit a copy of the full birth/adoption certificate(s) in support of your claim. Child s forename Your date of birth Gender Child s forename Date of birth Gender F. Dental injury Name of claimant Date of injury Cause of injury G. Funeral grant Please submit a copy of the full death certificate in support of your claim. Name of claimant Name of deceased Relationship to deceased H. Hospital admission I authorise the hospital to disclose in section H the reason for my admission. Patient s signature (or signature of legal guardian and relationship to patient if claimant is under 16) Date

4 To be completed by the hospital Full name of patient Hospital number Signature of authorising officer Position held As an in-patient, admitted on Discharged on If during the above period the patient was away from hospital for one or more nights please provide details. OR as a day-patient surgery admission on from Official hospital stamp to from to The patient was admitted for the following reason (please tick as appropriate) Accident or casualty admission Convalescence or rehabilitation care Geriatric care in-patient for treatment Mental health or psychiatric treatment Ante/postnatal treatment care for social/domestic reasons Elective cosmetic surgery Corrective eye surgery In-patient for treatment Please state the condition for which the patient was admitted Was this episode linked to a chronic condition or a pre-existing condition (diagnosed or non-diagnosed) with symptoms experienced within the last 12 months? Yes No Parental stay I confirm that (name of parent) Stayed overnight with patient from to I. Member declaration I declare that I am not claiming for this claim under other health insurance that I hold (excluding claims for hospital stays, maternity and adoption grants and funeral grants). I understand that any fraudulent claims may result in legal action being taken and the immediate cancellation of my policy. I authorise any medical practitioner, or any other person(s) concerned with providing healthcare, to provide Bupa with any information that may be relevant to this claim. If submitting any information on behalf of another member covered by my policy, I also confirm that I am doing so with their knowledge and permission. I declare the information shown on this form and any accompanying documentation is true and correct. Member signature Date

5 Privacy notice in brief This privacy notice should be read alongside our full privacy notice. The full notice and a list of the trading companies that make up the Bupa group, can be found at bupa.co.uk/privacy. By providing your information, you consent to the use of your data and information as described in the full privacy notice and cookie policy. If we make a change to any of the ways in which we process personal information, we will update this notice on bupa.co.uk/privacy so please check back regularly for updates. You can also and ask us to send you the latest version at any time. Personal information In providing you with our services, Bupa may handle your personal information, which may include sensitive personal information such as medical information. We are very aware that you trust us to keep this information confidential and that is why we comply with UK data protection law and follow medical confidentiality guidelines issued by professional bodies. Securing information We are committed to keeping your personal information secure. We have put in place physical, electronic and operational procedures intended to safeguard and secure the information we collect. Information we may hold about you The information we hold about you may include personal and sensitive personal information. We may collect this information during contacts we have with you or with third parties who provide information about you, and from other sources including from your use of websites and other digital platforms. When we collect your information Information about you is collected when you engage with Bupa or the Bupa group of companies either by entering into a contract with Bupa, submitting a query or enquiry, applying for a quote or policy or participating in marketing activity. We may collect personal information about you from other people when you are named in an application form or as a dependant under a scheme, when we process an application or claim or when we obtain medical reports, or when we liaise with your family, employer, health professional or other treatment or benefit provider. You confirm that you consent to Bupa obtaining medical and billing information from your treatment provider relating to claims or complaints you may make. Using your information We use your personal information to provide you with our services, and to improve and extend our services. Sharing information Information about you may be shared by the companies in the Bupa group to enable us to manage our relationship with you as a Bupa customer and update and improve our records. Bupa works with other individuals and organisations to provide our services to you. This may involve them handling your personal information, which may be done outside of the European Economic Area. We ensure that the confidentiality and security of your personal information is protected by contractual restrictions and service monitoring. You may receive Bupa private medical services where another member of your family is the main member of the scheme or services. In that case we send all membership documents and confirmation of how we have dealt with any claim you make to the main member. You may receive Bupa services where your employer, or the employer of another member of your family, is the policyholder or pays for the scheme or services. In that case, we may share your information with the employer, the employer s insurance broker, or the trustees of your scheme. This will be explained in your policy documents. Keeping information We will only keep your personal information for as long as is necessary and in accordance with UK law. Keeping you informed The Bupa group would like to let you know more about our products and services. From time to time we might contact you (by post, , phone or SMS text) with information we think might interest you. If you do not wish to receive marketing information, or at any time you change your mind about receiving these messages, please contact the Bupa UK Information Governance Team, their contact details can be found below. Accessing information If you have any data protection queries, please contact the Bupa UK Information Governance team on or write to 4 Pine Trees, Chertsey Lane, Staines-upon-Thames TW18 3DZ You should also contact the team if you would like a copy of the personal information we hold about you and to ask us to correct or remove (where justified) any inaccurate information.

6 Bupa cash plan is provided by Bupa Insurance Limited. Registered in England and Wales No Bupa Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Arranged and administered by Bupa Insurance Services Limited, which is authorised and regulated by the Financial Conduct Authority. Registered in England and Wales No Registered office: Bupa House, Bloomsbury Way, London WC1A 2BA. Bupa 2016 bupa.co.uk CP/1596/AUG16 BHF 04105

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