Please use one claim per member

Mayfair Healthcare Scheme

Claim Form for: Vision Care, Dental, Prescription and General Practitioner Charges
This claim form is only to be used when claiming benefit for the above services. Please check the Guidelines
For Completion on the reverse of this form. If your claim is for medical advice or treatment please call the
Mayfair Help Desk on 0800 294 5637.

You may print out this form and complete it or enter your data directly on screen, using the tab key to move
between fields, and then print it.

Member details

Title

Date of
birth

First name
D

Surname
Y

Mayfair I.D. no.

Home
address

Postcode

Telephone
number

Email

Patient details

Date of
birth

Title

First name

Surname

Total cost of invoices/receipts

attached

Have the invoices/receipts been paid by you?

Treatment

Please indicate the type of treatment received making sure all sections of this form are completed.

Please tick against each option and list the invoices/receipts being submitted for assessment.

Dental

Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment

Cost

Cost

Cost

Cost

Cost

Optical

Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment

Cost

Cost

Cost

Cost

Cost

Conditions that
necessitate
treatment:
Details of services
supplied (e.g. dental
care, spectacle
lenses, spectacle
frames, out-patient
drugs etc).

General practitioner

Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment

Cost

Cost

Cost

Cost

Cost

Prescription charges

Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment
Date of
treatment

Cost

Cost

Cost

Cost

Cost

Yes

No

Members declaration
Signature of member

Date

Please print name

To be completed by the Patient or (if the Patient is under 18 years of age) the Patients Parent or Guardian

In order to determine whether your healthcare plan will cover the cost of your treatment, we might need to obtain a medical report
from your healthcare practitioner. Before your healthcare practitioner can give us medical information about you, you must give your
consent. Before giving your consent, you should be aware of your rights.
1. You may withhold your consent to the application being made or to the report being supplied to us.

2. You may see the report before it is sent to us. You must ask your healthcare practitioner for a copy within 21 days of the date on
which we request the report, which we will notify to you.
3. You may ask your healthcare practitioner for a copy of the report at any time up to six months after the date of the report.

4. You may ask your healthcare practitioner to amend any part of the report, which you consider to be incorrect or misleading. If the
healthcare practitioner does not agree with your request, you may attach your comments to the report.

5. Your healthcare practitioner may withhold the report from you, even though you have requested a copy, if he considers that it would
be harmful to your physical or mental health or if it contains information about a third party who has not consented to its disclosure.

If we require a medical report to enable us to consider your claim and you have not given your consent to us obtaining such a report, it
is unlikely that your healthcare plan will cover the cost of your treatment.

Patients declaration

Having been made aware of my statutory rights, I hereby consent to BCWA Administration Services Limited seeking medical
information from any healthcare practitioner who has attended me at any time concerning anything that affects my physical or mental
health and I authorise any such healthcare practitioner to disclose such information to the BCWA Administration Services Limited.
Signature

Date

Please print name

The patient

I confirm I am (please tick one)

The patients parent

The parents guardian

Guidelines for completion

Please complete this form to claim reimbursement for Vision Care, Dental, Prescription and General Practitioner charges.

Claims for reimbursement of prescription charges should be accompanied by a copy of the prescription and associated receipt.
Please ensure your GP, specialist or provider completes the declaration below.
Please use one claim form per family member.

Please obtain separate invoices/receipts for each family member.

Please ensure that your practitioner or pharmacy completes and stamps the declaration below.

In the case of a vision care or dental claim, please obtain a detailed receipt for services received.
Once completed, please submit the claim form and invoices/receipts to:

Mayfair Help Desk

Medisure
100 Temple Street
Bristol BS1 6EN

A reimbursement cheque up to the scheme limits will be forwarded to your home address.

If your claim is for medical advice or treatment, please contact the Mayfair Help Desk on 0800 294 5637.

To be completed by the patients healthcare practitioner

Signature

Practice/
Pharmacy
stamp

Name
D

Y
SP0083/1108

Date