Joining Worldwide Health Options Your Application

Transcription

1 Joining Worldwide Health Options Your Application

2 iportant inforation To join Bupa siply coplete the questions on this for. Please write clearly in BLOCK capitals using black ink. Once copleted, you can eail your for to or fax us on +44 (0) or post to Bupa International, Russell House, Russell Mews, Brighton, BN1 2NR, United Kingdo. If you feel that your eail is not secure, please send us your application for via post or fax. If you have faxed or eailed us then we do not need the original copy of your for. We look forward to welcoing you as a eber of Bupa. For full details of ters and conditions, please see a copy of our ebership guide available on request. If you have any questions when copleting this for, please call us on +44 (0) Checklist - please ake sure: you have read, signed and dated the declaration in section 13 the inforation you have given in sections 1-12 is correct and coplete for payents by Direct Debit or Credit Card, you have copleted the Direct Debit Instruction or the Credit Card Authority We will not be able to process your application if this for is incoplete. Please be sure to check the entire for. when you see this sign, it is referring to the ain eber 1 Main eber: your personal details The date you want your cover to start: D D M M Y Y Your cover cannot start before the date we receive your copleted application for. First nae Faily nae Male / Feale Nationality 1st Language Do you have current health cover with any other insurer, including Bupa? Yes If Yes, please give details of your cover: No Nae of other health insurer How long have you been with this insurer? Y Y M M Nae of schee / cover Mebership nuber 2 Residency address (this is the address where you spend ost of your tie or should be the country in which you are living on the first day of your current ebership year) Building Street Town/City Main eber: your address details (please let us know straightaway about any change of address) Correspondence address (where ebership docuents cannot easily be sent to you at your residency address, please supply an alternative address to which they ay be sent) Building Street Town/City Area code Region Country Area code Region Country If you have been living in the UK for 90 days or ore out of the last 120 days at the start of your current ebership year, then you are deeed resident in the UK. Does this apply to you? Yes No Are you a resident of the USA? Yes No 3 Main contact (hoe) Telephone Fax Main eber: your other contact details Country code Area code Nuber Secondary contact (work) Telephone Fax Country code Area code Nuber Mobile Eail Mobile Eail

3 1st additional person 4 Additional persons to be covered with you: personal details First nae Faily nae 1 Male / Feale Nationality 1st Language 2nd additional person 3rd additional person 4th additional person First nae Faily nae 2 Male / Feale Nationality 1st Language First nae Faily nae 3 Male / Feale Nationality 1st Language First nae Faily nae 4 Male / Feale Nationality 1st Language ngina/chest pains, heart aricose veins or Type 2), thyroid If any of these additional persons have different hoe or correspondence addresses to yours, please write their nae and addresses on a separate sheet and confir you have done so by ticking here: 5 Eail: Docuentation Main contact (hoe) Secondary contact (work) Other (below) iportant inforation - confidential edical history If you would like to view your ebership docuents online via MebersWorld instead of receiving the in the post, please tell us which eail address you would like us to send the link to. Please choose one of the following options: 4th additional person f breath, astha, COPD, chest rgies (including hayfever and les eg stoach inflaation/ ge in bowel habits, abdoinal pain, n, cirrhosis, gall stones or hernias ign growths, any cancers or pre- Sections 1 and 4: Personal details First nae Faily nae Male / Feale Nationality 1st Language Confidential edical history It is iportant that the inforation you give in sections 6 and 7 atches the correct persons fro sections 1 and 4. 6 Section 6: Confidential edical history 1. Heart or circulatory disorders eg high blood pressure, angina/chest pains, heart attack, heart failure, abnoral heart beat, aneuryss, or varicose veins 2. Endocrine (glandular) disorders eg diabetes (Type 1 or Type 2), thyroid probles, or obesity 3. Breathing or respiratory disorders eg shortness of breath, astha, COPD, chest infections, pneuonia, bronchitis, tuberculosis or allergies (including hayfever and anaphylaxis) 4. Stoach, intestines, liver or gall bladder probles eg stoach inflaation/ ulcers, irritable bowel, Crohn s disease, colitis, change in bowel habits, abdoinal pain, haeorrhoids/piles, pancreatitis, liver inflaation, cirrhosis, gall stones or hernias 5. Cancer, tuours or growths eg polyps, benign growths, any cancers or precancerous condition 6. Skin probles eg eczea, deratitis, rashes, psoriasis, acne, cysts, oles that itch or bleed, or allergic conditions 7. Brain or nervous syste disorders eg stroke, deentia, igraine, repeated headaches, ultiple sclerosis, epilepsy/fits, nerve pain (including sciatica and shingles) or eningitis Additional inforation This section asks for health and edical details, past and present about yourself and each person naed in Section 4. Please tick Yes or No to every question for every person. If you tick Yes to a question, please give full details in Section 7 on the next page. Please ensure you tell us about any known or suspected conditions and syptos even if professional advice has not yet been sought. If you are applying to increase cover and you are already a Bupa International eber, you should also include details of any conditions for which you have ade clais within the last four years. If you do not provide us with full details we ay terinate your cover or it ay stop us fro paying your clais. Have you or anyone to be covered under the ebership: seen a doctor or other healthcare professional in the last 3 years been aditted to hospital, had an operation/procedure or had an investigation (eg a scan/blood tests) in the last 7 years for any of the edical probles listed in question 1 12 below: 7 This section applies if you have indicated Yes to any questions in section 6. If you are unsure whether any details are relevant, you ust include the. The relevant Please specify as accurately as When did the syptos What treatent did you receive What was the outcoe question possible the nae of the illness or start and when was and when (please include of the treatent nuber edical proble. treatent copleted? dates, naes and details of (eg ongoing, coplete fro Where applicable, please state edications)? recovery, recurrent section 6 the area of the body affected, or likely to recur)? (eg right leg, left eye). Section 7: Additional inforation Follow these icons when referring to yourself and additional persons = Main eber = First additional person = Second additional person = Third additional person = Fourth additional person

4 6 Confidential edical history This section asks for health and edical details, past and present about yourself and each person naed in Section 4. Please tick Yes or No to every question for every person. If you tick Yes to a question, please give full details in Section 7 on the next page. Please ensure you tell us about any known or suspected conditions and syptos even if professional advice has not yet been sought. If you are applying to increase cover and you are already a Bupa International eber, you should also include details of any conditions for which you have ade clais within the last four years. If you do not provide us with full details we ay terinate your cover or it ay stop us fro paying your clais. Have you or anyone to be covered under the ebership: z seen a doctor or other healthcare professional in the last three years z been aditted to hospital, had an operation/procedure or had an investigation (eg a scan/blood tests) in the last seven years for any of the edical probles listed in question 1 12 below: Heart or circulatory disorders eg high blood pressure, angina/chest pains, heart attack, heart failure, abnoral heart beat, aneuryss, or varicose veins 2. Endocrine (glandular) disorders eg diabetes (Type 1 or Type 2), thyroid probles, or obesity 3. Breathing or respiratory disorders eg shortness of breath, astha, COPD, chest infections, pneuonia, bronchitis, tuberculosis or allergies (including hayfever and anaphylaxis) 4. Stoach, intestines, liver or gall bladder probles eg stoach inflaation/ ulcers, irritable bowel, Crohn s disease, colitis, change in bowel habits, abdoinal pain, haeorrhoids/piles, pancreatitis, liver inflaation, cirrhosis, gall stones or hernias 5. Cancer, tuours or growths eg polyps, benign growths, any cancers or precancerous condition 6. Skin probles eg eczea, deratitis, rashes, psoriasis, acne, cysts, oles that itch or bleed, or allergic conditions 7. Brain or nervous syste disorders eg stroke, deentia, igraine, repeated headaches, ultiple sclerosis, epilepsy/fits, nerve pain (including sciatica and shingles) or eningitis 8. Muscle or skeletal probles eg arthritis, back pain, neck/shoulder probles, cartilage and ligaent probles, joint replaceents, fractures, osteoporosis, gout or inflaatory conditions. 9. Urinary or reproductive syste probles eg kidney or bladder probles (including kidney failure), recurrent urinary infections, incontinence; pregnancy/ childbirth probles (including caesarean sections), heavy or irregular periods, fibroids, endoetriosis, infertility, abnoral sears, polycystic ovaries, testicular or prostate disorders. 10. Blood/infective/iune disorders eg abnoral blood tests, high cholesterol, anaeia; hepatitis, HIV, alaria; or any autoiune disorder. 11. Eye, ear, nose, throat and dental probles eg cataracts, glaucoa, visual ipairent; deafness, ear infections, tonsillitis; dental infections, wisdo teeth probles or gingivitis. 12. Psychiatric/ psychological disorders eg schizophrenia, copulsive or eating disorders; depression, stress, anxiety or drug/alcohol dependency. Please also answer the following questions: 13. Is anyone to be covered taking any edication, prescribed or otherwise? 14. Is anyone to be covered receiving any treatent of any kind, or require or expect to require any review, investigations or treatent for any current or past edical proble not already entioned in this application? 15. Has anyone to be covered experienced any signs or syptos of any edical proble in the last six onths, regardless of whether a health care professional has been consulted? Further details (for over 16s only): How tall are you? feet/inches etres/centietres How uch do you weigh? stones/pounds kilograes Have you used tobacco products within the last seven years?

5 7 Additional inforation This section applies if you have indicated Yes to any questions in section 6. If you are unsure whether any details are relevant, you ust include the. The relevant question nuber fro section 6 Please specify as accurately as possible the nae of the illness or edical proble. Where applicable, please state the area of the body affected, (eg right leg, left eye). When did the syptos start and when was treatent copleted? What treatent did you receive and when (please include dates, naes and details of edications)? What was the outcoe of the treatent (eg ongoing, coplete recovery, recurrent or likely to recur)? N.B. Please tell us iediately if you or any additional persons to be covered under the ebership experience any syptos before you receive your ebership docuents. Failure to do so ay affect your clais. If there is insufficient space, please use a separate sheet and indicate that you have done so by ticking this box: 8 If you have a regular/faily doctor, please fill in the below details Doctor s nae Full postal address Your consent to your doctor to disclose edical inforation. On behalf of yself and each person naed on this for, I authorise this doctor to provide Bupa International with any inforation it asks for in connection with y ebership application and any clais (past, present and future). If any faily ebers included in your application have a different doctor, please give the nae and / or address details on a separate sheet - and confir you have done so by ticking here:

6 9 Choose your cover options Worldwide Medical Insurance For treatent received whilst staying in hospital, either overnight or as a daycase, plus related benefits. Worldwide Medical Insurance gives you the reassurance of covering any essential hospital treatent you ay need, whether in an eergency or a planned visit. All surgery, cancer treatent and advanced iaging, whether received whilst staying in hospital or as a visiting patient, are also included. Each eber to be included on this plan autoatically receives cover for Worldwide Medical Insurance, our core cover. Please tick the options you wish to add for you and any additional people. Worldwide Medical Plus: For specialist treatent where you do not need to stay in hospital. Worldwide Medical Plus covers you for consultations with a doctor or specialist and edical treatents that do not require a hospital stay. These ay include osteopathy or copleentary therapies, for exaple. Soe of these treatents or consultations ay take place before or after a hospital stay, but any will be totally independent. Worldwide Medicines and Equipent: For prescribed edicines and edical equipent. Often, treatent does not end when you leave the hospital or clinic or after you have seen a specialist. This option covers you for prescription edicines and the rental of edical appliances, such as oxygen supplies, including asks and tubes or wheelchairs. Our unique benefit for long-ter prescriptions will also pay for any edicine required to anage chronic conditions such as astha. Worldwide Wellbeing: For a range of health screenings, vaccinations, dental and optical treatent. Our Wellbeing option is designed to help you protect and aintain your health. It covers edical screenings that can provide valuable early detection of conditions such as cancer. It covers dental and optical treatents, which can play an iportant role in keeping you healthy by identifying underlying probles such as outh cancer or diabetes. Worldwide Evacuation: For when you can t get the treatent you need in a local hospital. The Worldwide Evacuation option is ideal if you are concerned about the quality of local care. It covers you for reasonable transport costs to the nearest suitable edical centre, when the treatent you need is not available nearby. Repatriation, which is also included, gives you the added option of returning to your hoe country or specified country of nationality, to be treated in failiar surroundings. USA cover: If you spend ost of your tie in the USA, then you will need to buy USA cover on an annual basis. If you spend ost of your tie outside the USA, you can choose to add USA cover to your plan by ticking in this section. Please note, we do not cover peranent USA residents. Annual Deductible If you are paying by Direct Debit or Credit Card, you ay choose an annual deductible. This is the aount you would pay towards eligible edical treatent each year. If you choose any of the deductible aounts on Worldwide Medical Insurance then a fixed deductible aount of 100 ($170 / 125) is applied to Worldwide Medical Plus and 50 ($80 / 60) fixed deductible aount is applied to Worldwide Medicines and Equipent (if you choose these options). The deductible you choose will apply to each eber on this for. GBP: None USD: None $425 $850 $1700 $3400 $8500 EUR: None

7 10 Your payent details (Direct debit, credit card or cheque/bankers draft) Your choice of currency for your cover and subscription payents (please tick one only): GBP( ) USD($) EUR( ) How will you ake your subscription payents (please tick one only): Monthly Quarterly Yearly You ust choose to pay by direct debit or credit card if you have chosen a deductible. By direct debit through a UK bank. (This is only an option for GBP( ) payents. Please coplete the below Direct Debit Instruction): By credit card (please coplete the below Card Payent Authority): By cheque or bankers draft in the currency you have indicated above: Please note, when choosing to pay via cheque or bankers draft, you can not pay onthly or have a deductible. Please fill in the nae of the person paying the subscription in the box provided below when choosing to pay via cheque or bankers draft. Nae: A valid Direct Debit agreeent or Card Authority is required throughout your ebership year. Your cover ay be suspended or terinated if you do not have such an agreeent or authority in place. 11 Direct Debit (for GBP ( ) payents only - this ust coe out of a UK bank account) If you are paying by Direct Debit you ust coplete this section Instruction to your Bank or Building Society to pay by Direct Debit Nae(s) of account holder(s): Bank/Building Society account nuber: Branch sort code: - - Swift code: Nae and full postal address of your Bank/Building Society: Instruction to your Bank or Building Society Please pay Bupa International Direct Debits fro the account detailed in this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction ay reain with Bupa International and, if so, details will be passed electronically to y Bank/Building Society. To: The Manager Address: Postcode: Account holder s signature Date Reference nuber (for Bupa International use only) BI Originator s ID nuber Banks and Building Societies ay not accept Direct Debit Instructions for soe type of accounts. As Instruction For 12 Credit Card authority Card payent authority To Bupa International, I authorise you, until further notice in writing, to charge to y card account, subscriptions and other unspecified aounts, as and when payents becoe due. I will advise you iediately if the card becoes lost, stolen or if I wish to close y card account or cancel the authority. Cardholder s nae as it appears on the card: (please tick) MasterCard Visa Aerican Express Please note that we do not accept Maestro payents. You will be given 14 days notice of other unspecified aounts to be collected. Card nuber: Valid fro date: Expires/end date: / / Cardholder s signature Date The Direct Debit Guarantee This guarantee should be detached and retained by the payer z This Guarantee is offered by all banks and building societies that take part in the Direct Debit Schee. The efficiency and security of the Schee is onitored and protected by your own Bank or Building Society. z If the aounts to be paid or the payent dates change, Bupa International will notify you 7 working days in advance of your account being debited or as otherwise agreed. z If an error is ade by Bupa International or your Bank or Building Society, you are guaranteed a full and iediate refund fro your branch of the aount paid. z You can cancel a Direct Debit at any tie by writing to your Bank or Building Society. Please also send a copy of your letter to us.

8 13 Your ebership declaration In view of the declaration below, it is essential that coplete inforation is supplied. Benefits ay not be payable if you do not fully disclose any aterial facts which could influence our assessent and acceptance of this application and, if you are in any doubt as to whether any facts are aterial, you should disclose the. You are advised to keep a record of all inforation you supply to us in connection with this application, including letters. If you would like a copy of this application for, please ask us. It is Bupa International s intention to provide a first class service to our ebers at all ties. However, if you do have any cause for dissatisfaction, please write to the Director of Operations at Bupa International s Head Office. The address is, Bupa International, Russell Mews, Brighton BN1 2NR, United Kingdo. If you reain dissatisfied you ay appeal to the Managing Director by writing to hi at the sae address. Unless otherwise agreed by Bupa International in writing, English Law shall apply to the agreeent between you and Bupa International. I hereby apply to be enrolled as a Meber with the Dependants listed above included in y ebership. I declare that to the best of y knowledge and belief the inforation given in this Application is true and coplete. I agree that the Rules of the Bupa International schee will be binding on e and all eligible Dependants included in y ebership. I agree that any cover which I ay purchase for the USA shall terinate upon inforing Bupa International that I have becoe a resident of the USA. I confir that I give explicit consent, within the provisions of the Data Protection Act 1998, on behalf of yself and any faily ebers specified in this for for Bupa International to process our personal inforation with respect to our ebership and I confir that I have brought the Data Protection Notice to the attention of these faily ebers. Identification stap / broker nae and ID nuber Bupa International Data Protection Notice Purpose: Personal data collected on you, and where appropriate, your faily, will be used by Bupa International to process your clais, adinister your policy and ay be used to detect and prevent fraud or iproper clais. Confidentiality: The confidentiality of patient and eber inforation is of paraount concern to Bupa International. To this end, Bupa International fully coply with UK Data Protection Legislation and Medical Confidentiality Guidelines. Bupa soeties uses third parties to process data on its behalf. Such processing, which ay be undertaken outside the European Econoic Area, is subject to contractual restrictions with regard to confidentiality and security in addition to the obligations iposed by the Data Protection Act. Medical inforation: Medical inforation will be kept confidential. It will only be disclosed to those involved with your treatent or care, including your General Practitioner/Priary Health Physician, or to their agents, and, if applicable, to any person or organisation who ay be responsible for eeting your treatent expenses, or their agents. Clais inforation ay be discussed with the Bupa International Agent/Adviser where you have requested the Adviser to assist you. Meber details: All ebership docuents and confiration of how we have dealt with any clai you ay ake will be sent to the principal eber. Telephone calls: In the interest of continuously iproving our service to ebers, your call will be recorded and ay be onitored. Research: Anonyised or aggregated data ay be used by Bupa International, or disclosed to others, for research or statistical purposes. Fraud: Inforation ay be disclosed to others with a view to preventing fraudulent or iproper clais. Naes and addresses: Bupa International does not ake the naes and addresses of ebers or patients available to other organisations. for office use only Keeping you infored: Bupa International would, on occasion, like to keep you infored of Bupa International products and services which it considers ay be of interest to you. Contact address: If you do not wish to receive inforation about Bupa International s products and services, or have any other Data Protection queries please write to the Bupa Group Inforation Protection Manager, at Bupa House, Bloosbury Way, London WC1A 2BA or at DataProtection@Bupa.co. iportant inforation - YOUR MEMBERSHIP DECLARATION Please be aware that this for ust be received by Bupa International no ore than six weeks after the declaration date. It is advisable that you fill in your for with coplete up-to-date edical history before you sign and date this for. If we receive this for after six weeks fro this signed declaration date, or with incoplete inforation, we will be unable to register your details and enrol you on the plan. Please use the checklist on the front of the for to ensure you have filled everything in copletely. Signature Date IN-BWHO-APF-09v1