Submit Your Insurance Details

Submitting you Health Insurance Details

To be submitted by ALL patients who intend to make a direct settlement through their Private Health Insurance Scheme before their appointment with Body Back-Up.

All details will be kept confidential.

Patient Details

Patient Name (required)

Email (required)

Patient Case Number

Date of Initial Consultation

Referring GP's Name

Policy Details

Insurance Company Name:

Patients Claim Number:

Policy Reference Number:

Policy Holders Name:

Employer's Details (for corporate Policy Holders only)

Employer's Name:

HR/Plan Administrator Number:

Declaration: The above information is correct to the best of my knowledge. I understand that if, for any reason, my Health Insurance Company will not accept this claim, either in part or in full, then I am responsible for the balance of payment for all goods and fees incurred.

Please enter the numbers/letters you see below