HSEU SCHEME III BENEFIT CLAIM FORM

HSEU SCHEME III BENEFIT CLAIM FORM
Only HSEU members who have fully paid up subscriptions and Mutual Aid Scheme III payments at the time of hospitalization are eligible.
The member must be hospitalized in a Singapore restructured or recognized private hospital.
**Please submit this completed claim form with the final hospital bills to HSEU within 2 months from the date of discharge.**
PERSONAL PARTICULARS
NAME OF MEMBER (CLAIMANT):
COMPANY:
EMPLOYEE NO:
GENDER:
ADDRESS:
NRIC:
OCCUPATION:
DATE OF BIRTH:
CONTACT NUMBER:
AGE:
(HOME)
EMAIL:
(MOBILE)
(OFFICE)
DETAILS OF HOSPITALISATION
Hospital admitted to:
Admitted on (DD/MM/YY): __________ / ___________ / ___________
Discharged on (DD/MM/YY): __________ / ___________ / ___________
Nature of injury or illness:
1.
I, the undersigned, declare that the particulars stated in this application form are true and correct, and that I have not wilfully withheld any material fact.
2.
I note that I may be required to furnish other supporting documents for verification and audit purposes.
3.
I consent to my personal data being collected, used and retained by HSEU for the purposes of:
4.
(a)
processing, administering and managing my application for the HSEU Scheme III and
(b)
carrying out verification and updates of my membership status and/or information I have provided in this application form.
I consent to be contacted by HSEU via email, text messages, fax and/or post for matters relating to my application for the HSEU Scheme III and other membership matters.
5.
I consent to HSEU obtaining/ providing information about me from/ to any medical source, insurance office, organization or person.
6.
I agree that a photocopy of this form shall be as valid as the original.
7.
I further declare that the personal data pertaining to my beneficiary is true and correct and that he/she is aware and consents to HSEU managing their
information for authorised purposes.
SIGNATURE OF MEMBER (CLAIMANT)
DATE:
CERTIFICATION OF UNION MEMBERSHIP (FOR HSEU’S USE ONLY)
DATE JOINED UNION (DD/MM/YY):
PAYMENT CHECKED FOR UNION: YES / NO
PAYMENT CHECKED FOR MAS III: YES / NO
I HEREBY CERTIFY THAT THE ABOVENAMED IS A FULLY PAID UP MEMBER OF HSEU.
NAME/ SIGNATURE OF AUTHORISED
NAME/ SIGNATURE OF BRANCH OFFICIAL:
NAME/ SIGNATURE OF HQ OFFICER:
OFFICER:
DATE:
DATE:
DATE:
NUMBER OF HOSPITAL DAYS:
TOTAL PAYABLE: S$
HSEU SCHEME III BENEFIT CLAIM FORM
CHECKLIST FOR CLAIM SUBMISSION (FOR HSEU’S USE ONLY)
No For Branch Official
Tick
1 Application Form should be attached with hospital bill
2 Supportive document for any late submission
3
The form must be fully completed and signed by member.
Nature of illness must be indicated under “Details of Hospitalization” column
4 Emergency cases admitted to hospital for observation is not covered by Scheme III.
For Full-Time Branch Official
5 Ensure claimant is a fully paid up member for both Union and Scheme III fees.
6 Ensure member hospitalized in Singapore restructured or recognized private hospital.
7
Complete “Certification of Membership” column and Enclose a copy of UXS biodata of member
HEALTHCARE SERVICES EMPLOYEES’ UNION
TEL: 6222 1227
NO. 3 BUKIT PASOH ROAD #02-00 SINGAPORE 089817
FAX: 6222 6683
EMAIL: [email protected]
WEBSITE: www.hseu.org.sg
With effect from 8 August 2014

Download Report