Austhealth com or call 1800 22 11 33

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nib276522_0418

Visit 

austhealth.com or call 1800 22 11 33

1

IMAN Australian Health Plans Pty Ltd  ABN 34 144 907 746

a subsidiary of nib holdings limited  ABN 51 125 633 856

CLAIM FORM

  Please credit my SafeClaim account (if you have authorised IMAN to credit your account using a Direct Credit Authority Form)

  Please send me a cheque made out in my name

  Please send me a cheque made out in my partner’s name (only available if you have authorised IMAN to do this)

If you have not yet paid the account, IMAN will send you a cheque to forward to your provider. You will need to pay the rest            

of your bill.

Please note: Claim benefits are paid by nib health funds limited abn 83 000 124 381 (on behalf of IMAN Australian Health Plans Pty 

Ltd ABN 34 144 907 746).

How do you want IMAN to pay your claim?

STEP 3

1. Is any part of your IMAN health premium either reimbursed or directly paid for by your Sponsor/Employer?  Yes 

   No 

 

    If you answered Yes to question 1 above please skip question 2.

2. Do you have an Australian Business Number (ABN), and are you registered for Goods and Services Tax (GST)?  Yes 

   No 

Please answer the below questions

STEP 4

Your family name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    Your first name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Your current postal address (this is the address we will send any correspondence to do with this claim)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

State. . . . . . . . . . . . . . . . . . . .    Postcode. . . . . . . . . . . . . . . . .    Daytime Phone number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Policy Number

Complete your policy details

STEP 1

I am claiming everyday Extras (e.g. General Dental, Optical, Physiotherapy, Prescriptions)

Date of 

service

Type of service

Name of the provider

Patient name

Is this related to 

compensation?

Is the account 

paid in full?

Yes 

   No 

Yes 

   No 

Yes 

   No 

Yes 

   No 

Yes 

   No 

Yes 

   No 

Yes 

   No 

Yes 

   No 

Complete the details of your claim

STEP 2

I am claiming medical services (e.g. Hospital, Doctor and Specialist fees)

Date of 

admission

Date of 

discharge

Name of the provider

Is this related to 

compensation?

Is this the result  

of an accident?

Is this account 

paid in full?

Yes 

   No 

Yes 

   No 

Yes 

   No 

Yes 

   No 

Yes 

   No 

Yes 

   No 

Do you have a Medicare card?  Yes 

   No 

If you answered Yes:   Type of card (please tick)    Permanent 

   Interim 

   Reciprocal 

Card number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    Start Date ____ /________    Expiry Date ____ /________

---

nib276522_0418

Visit 

austhealth.com or call 1800 22 11 33

2

IMAN Australian Health Plans Pty Ltd  ABN 34 144 907 746

a subsidiary of nib holdings limited  ABN 51 125 633 856

TO SUBMIT YOUR FORM

Complete your form and submit in one of the following ways:

Mail

IMAN Australian Health Plans

Reply Paid 62208                        

Locked Bag 2010                              

Newcastle NSW 2300

If you have questions call the Customer Contact Centre:

Monday to Friday  8.30am – 6.00pm (AEDT)

Call 1800 22 11 33

From overseas [phone]

  I have attached all the receipts and/or accounts for each item I am claiming.

  All the receipts/accounts I have attached are original, itemised in full, written in English, and are on the provider’s official 

stationery or have the provider’s official stamp.

  I received the services within the last two years. (IMAN does not pay claims made two years or more after the services        

were received)

  I am claiming services from an IMAN recognised provider. (IMAN does not pay claims for the services of providers who are     

not recognised by IMAN)

  I have indicated where applicable that the claim is related to worker’s compensation.

CLAIMS CHECKLIST

Read the following important information and sign this form

STEP 5

Your Signature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   Date ____ /____ /________

(or your authorised partner)

By signing this form, I declare that all information I have provided to IMAN, including all information in this form, is true & 

correct. I authorise IMAN to use this information and any other information I have previously given IMAN to assess and 

process my claim(s). I consent to IMAN contacting my previous health fund and/or service provider to request information 

and/or personal and medical records to verify any aspect of the claim(s). I acknowledge and provide consent for IMAN to 

use this information for other purposes related to this claim as outlined in the IMAN Privacy Policy.

I confirm these services have not been claimed as Point of Service such as HICAPS and that this claim is not subject to 

workers compensation, damages action, third party insurance or any other source.

I confirm that the services I am claiming were performed by the providers, and received by the persons as indicated on the 

healthcare provider’s receipts.

Log into Online Services at 

austhealth.com