Medical Report
Medical Report
Medical Report
practitioner’s
questionnaire
Bu~
Before you begin
Your cover excludes cover for certain pre-existing conditions. See your documentation for full details. This form is required
before you make a claim to determine eligibility.
Please read the following carefully before completing the form
J
To allow us to confrm if the treatment you require is eligible under your Bupa policy or your trust scheme, please
complete sections 1 to 5.
J
Ask your healthcare practitioner (that holds your medical records with regards to your claim) to complete sections 6
and 7 and return this form to us together with your referral letter. Without this, your claim may take longer than normal.
Please bear in mind that if you’re newly registered with your healthcare practitioner, they may not have all the relevant
records, which may cause a delay if we need to ask for more information.
J
The healthcare practitioner who completes sections 6 and 7 of this form may charge you for doing this. Bupa will
contribute £15 (inclusive of VAT) towards the cost, provided the conditions/symptoms were not present prior to your
Bupa start date.
J
Please be aware that you will need to pay for any costs that are not covered under your Bupa policy or your
trust scheme if you go ahead with private consultations, treatment or tests before we have confrmed whether
you’re covered.
J
Your cover is subject to the rules and benefts of the scheme that apply to you at the time you receive your treatment.
We’re here to help
If you have any queries when completing this form,
J
for Mental Health, please call the Bupa Mental Health Team on 0345 600 5446*. Lines are open Monday to Friday
8am to 8pm and between 8am to 4pm on Saturdays,
J
for any other conditions, please call the Bupa Medical Assessment Team on 0345 600 8630*. Lines are open
Monday to Friday 8am to 5pm.
For people with hearing or speech diffculties you can use the Relay UK service on your smartphone or textphone.
For further information visit www.relayuk.bt.com. We also offer documents in Braille, large print or audio.
2
1. Your personal details
Please tell us about yourself here (to see how we use your information, please read our privacy notice on
page 10).
Postcode EN40HS
Date of birth
□□□□□□□□
D3 D0 M0 M
4 1
Y 9
Y 7Y 7Y
□□□□□□□□□□
Your Bupa membership/registration number 0 5 4 7 5 4 6 1 6 7
If you’ve been in an accident or suffered medical negligence and are taking legal action against another
person, we will contact your solicitor to make sure that any claims payments we make are included in
your claim.
Date of accident/medical negligence incident
□□□□□□□□
D D M M Y Y Y Y
□ □
Is legal action being taken? Yes No
Name
Address
Postcode
B. Other insurance
If you have any other insurance that covers medical expenses, please give the name(s) of the insurer(s)
concerned, in case we need to contact them.
Insurer Policy number
3
3. About your condition
Please give details of your condition, any symptoms you’ve experienced and your reasons for seeking
medical advice.
I first noticed a white spot on my tongue, i thought it was an ulcer at first but after using bonjela it didnt work i called my GP. He
had a look at it and prescribed me with mouthwash I used it for a couple of weeks, nothing happened so i then called back my
GP and he asked to see me. He said it was a cyst and needed to be referred to have it removed. It starts of small but seems to
chage colour, size and shape sometimes i cant feel it and other times its uncomfortable when im eating.
When did you frst notice the symptoms (not just this episode)? Date
□□□□□□□□
D0 D9 M
0 9
M 2
Y 0Y 2Y 1Y
Please give dates of all episodes when you experienced symptoms or received treatment (including
medication, prescribed by your healthcare practitioner or over the counter) for this condition.
Symptoms/treatment
Date
□□□□□□□□
D D M M Y Y Y Y
Date
□□□□□□□□
D D M M Y Y Y Y
4
Please give dates of all episodes when you experienced symptoms or received treatment (including
medication, prescribed by your healthcare practitioner or over the counter) for this condition.
Symptoms/treatment
i was seen by my GP who said it was a cyst and needed to be referred Date
□□□□□□□□
D2 D0 M
1 0
M 2
Y 0Y 2Y 1Y
Date
□□□□□□□□
D D M M Y Y Y Y
Date
□□□□□□□□
D D M M Y Y Y Y
Date
□□□□□□□□
D D M M Y Y Y Y
Email address
5
5. Medical reports – when we need more information from your doctor
□ □
I confrm that I am the patient/member/benefciary Yes ✔ No
□ □
Is the patient/member/benefciary under 16 years of age? Yes No ✔
□ □
If yes, I confrm that I am the parent/legal guardian Yes No
When we need to ask your doctor for more information, in writing about your consultation, tests or treatment, we’ll need your
permission. The Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (NI) Order 1991
give you certain rights, which are:
1. You can give permission for your doctor to send us a medical report without asking to see it before they send it to us.
2. You can give permission for your doctor to send us a medical report and ask to see it before they send it to us.
J
You’ll have 21 days from the date we ask your doctor for your medical report to contact them and arrange to see it.
J
If you don’t contact your doctor within 21 days we’ll ask them to send the report straight to us.
J
You can ask your doctor to change the report if you think it’s inaccurate or misleading. If they refuse, you can insist on
adding your own comments to the report before they send it to us.
J
Once you’ve seen the report, it won’t be sent to us unless you give your doctor permission to do so.
3. You can withhold your permission for your doctor to send us a medical report. If you do, we’ll be unable to see whether
the consultation, test or treatment is covered by your policy, and we won’t be able to give you a pre-authorisation number
or confrm whether we can contribute to the costs.
In any event you also have the right to ask your doctor to let you see a copy of your medical report within six months of it
being sent to us.
Your doctor can withhold some or all the information in the report if, in their view, the information:
J
might cause physical or mental harm to you or someone else or
J
would reveal someone else’s identity without their permission (unless the person is a healthcare professional and the
information is about your care provided by that person).
I understand that Bupa will contribute £15 (inclusive of VAT) towards the cost of this medical report, provided the conditions/
symptoms were not present prior to my Bupa start date. I agree that I will be liable for any amount above this.
Date
□□□□□□□□
D1 D3 M
0 1
M 2
Y 0Y 2Y 2Y
We’ll verify your digital signature if your form is signed using an Adobe Digital ID or Adobe Sign
(or equivalent). If you modify your form after digitally signing it, or send us a printed or a scanned copy
of the form, then we won’t be able to verify your digital signature at this point and will need to contact
you either by phone or in writing to confrm this is your signature. Until we have verifed or confrmed
your signature, we won’t be able to advise exactly what your policy covers you for, meaning your
claims might take longer for us to process and we might not be able to pay for treatment you need.
6
6. Medical details – to be completed by the healthcare practitioner
Your healthcare practitioner must complete this section and attach your referral letter(s) to make sure
we can process your claim as quickly as possible. Please note that if your healthcare practitioner charges
for completing this form, Bupa will contribute £15 (inclusive of VAT) towards the cost, provided the
conditions/symptoms were not present prior to your Bupa start date.
Please specify how long this patient has been registered with your practice and if you have access to their full notes.
Details of the patient’s condition or symptoms and outline the treatment plan if known at this stage
When were the very frst signs and symptoms of this condition Date
(not just this episode)? □□□□□□□□
D D M M Y Y Y Y
When did the patient frst consult you or any other healthcare Date
practitioner about this symptom/condition? □□□□□□□□
D D M M Y Y Y Y
Time of appointment
Has the patient suffered from any related conditions or symptoms? Yes No
□ □
Please provide all medical history relating to the condition for which the patient is claiming, and any related conditions,
symptoms or treatment received in chronological order. If the patient has suffered any similar symptoms or conditions, please
provide your rationale as to if and how this condition is related/unrelated to the above symptom/condition.
Symptoms/treatment Date
□□□□□□□□
D D M M Y Y Y Y
□□□□□□□□
D D M M Y Y Y Y
□□□□□□□□
D D M M Y Y Y Y
7
Please provide all medical history relating to the condition for which the patient is claiming, and any related conditions,
symptoms or treatment received in chronological order. If the patient has suffered any similar symptoms or conditions, please
provide your rationale as to if and how this condition is related/unrelated to the above symptom/condition.
Symptoms/treatment Date
□□□□□□□□
D D M M Y Y Y Y
□□□□□□□□
D D M M Y Y Y Y
□□□□□□□□
D D M M Y Y Y Y
□□□□□□□□
D D M M Y Y Y Y
□□□□□□□□
D D M M Y Y Y Y
□□□□□□□□
D D M M Y Y Y Y
□□□□□□□□
D D M M Y Y Y Y
8
7. Fee – to be completed by the healthcare practitioner
Bupa will contribute £15 (inclusive of VAT) towards the cost of this medical report, provided the conditions/symptoms
were not present prior to the member’s Bupa start date. Please note that eligible payments cannot be made prior to
receipt of the report.
Patient has paid the fee – please send payment to the patient
□
Patient has not paid the fee – please send payment to the Healthcare Practitioner
□
For payment to healthcare practitioner, please choose payment type and provide details.
Cheque
□
Payee name
BACS
□
□□ □□ □□ □□□□□□□□
Sort code – – Account number
Postcode
I confrm that the information in this form is accurate and complete as at the date of signature, to the best of my
knowledge and belief.
Address
Postcode
Date
□□□□□□□□
D D M M Y Y Y Y
9
Privacy notice – in brief
We are committed to protecting your privacy when dealing 6. Processing for profling and automated decision-making
with your personal information. This privacy notice provides an Like many businesses, we sometimes use automation to provide
overview of the information we collect about you, how we use you with a quicker, better, more consistent and fair service, as well
it and how we protect it. It also provides information about your as with marketing information we think will interest you (including
rights. The information we process about you, and our reasons discounts on our products and services). This may involve
for processing it, depends on the products and services you use. evaluating information about you and, in limited cases, using
You can fnd more details in our full privacy notice available at technology to provide you with automatic responses or decisions.
bupa.co.uk/privacy. If you do not have access to the internet and You can read more about this in our full privacy notice. You have
would like a paper copy, please write to Bupa Data Protection, the right to object to direct marketing and profling relating to
Willow House, 4 Pine Trees, Chertsey Lane, Staines-upon-Thames, direct marketing. You may also have rights to object to other
Middlesex TW18 3DZ. If you have any questions about types of profling and automated decision-making.
how we handle your information, please contact us at
7. Sharing your information
dataprotection@bupa.com
We share your information within the Bupa group of companies,
Information about us with relevant policyholders (including your employer if you are
In this privacy notice, references to ‘we’, ‘us’ or ‘our’ are to Bupa. covered under a group scheme), with funders who arrange
Bupa is registered with the Information Commissioner’s Offce, services on your behalf, those acting on your behalf (for example,
registration number Z6831692. Bupa is made up of a number brokers and other intermediaries) and with others who help us
of trading companies, many of which also have their own provide services to you (for example, health-care providers) or
data-protection registrations. For company contact details, who we need information from to handle or check claims or
visit bupa.co.uk/legal-notices entitlements (for example, professional associations). We also
1. Scope of our privacy notice share your information in line with the law. You can read more
This privacy notice applies to anyone who interacts with us about about what information may be shared in what circumstances
our products and services (‘you’, ‘your’), in any way (for example, in our full privacy notice.
email, website, phone, app and so on). 8. International transfers
2. How we collect personal information We work with companies that we partner with, or that provide
We collect personal information from you and from certain other services to us (such as health-care providers, other Bupa
organisations (those acting on your behalf, for example, brokers, companies and IT providers) that are located in, or run their
health-care providers and so on). If you give us information about services from, countries across the world. As a result, we transfer
other people, you must make sure that they have seen a copy your personal information to different countries including transfers
of this privacy notice and are comfortable with you giving us from within the UK to outside the UK, and from within the EEA
their information. (the EU member states plus Norway, Liechtenstein and Iceland)
to outside the EEA, for the purposes set out in this privacy notice.
3. Categories of personal information We take steps to make sure that when we transfer your personal
We process the following categories of personal information information to another country, appropriate protection is in place,
about you and, if it applies, your dependants. This is standard in line with global data-protection laws.
personal information (for example, information we use to contact 9. How long we keep your personal information
you, identify you or manage our relationship with you), special
categories of information (for example, health information, We keep your personal information in line with periods we work
information about race, ethnic origin and religion that allows out using the criteria shown in the full privacy notice available
us to tailor your care), and information about any criminal on our website.
convictions and offences (we may get this information when 10. Your rights
carrying out anti-fraud or anti-money-laundering checks, or You have rights to have access to your information and to ask
other background screening activity). us to correct, erase and restrict use of your information. You also
4. Purposes and legal grounds for processing have rights to object to your information being used; to ask us to
personal information transfer information you have made available to us; to withdraw
We process your personal information for the purposes set out in your permission for us to use your information; and to ask us
our full privacy notice, including to deal with our relationship with not to make automated decisions which produce legal effects
you (including for claims and handling complaints), for research concerning you or signifcantly affect you. Please contact us
and analysis, to monitor our expectations of performance if you would like to exercise any of your rights.
(including of health providers relevant to you) and to protect 11. Data-protection contacts
our rights, property, or safety, or that of our customers, or others. If you have any questions, comments, complaints or suggestions
The legal reason we process personal information depends on about this notice, or any other concerns about the way in
what category of personal information we process. We normally which we process information about you, please contact us at
process standard personal information on the basis that it is dataprotection@bupa.com. You can also use this address to
necessary so we can perform a contract, for our or others’ contact our Data Protection Offcer.
legitimate interests or it is needed or allowed by law. We process
You also have a right to make a complaint to your local privacy
special categories of information because it is necessary for
supervisory authority. Our main offce is in the UK, where the local
an insurance purpose, because we have your permission or as
supervisory authority is the Information Commissioner, who can be
described in our full privacy notice. We may process information
contacted at: Information Commissioner’s Offce, Wycliffe House,
about your criminal convictions and offences (if any) if this
Water Lane, Wilmslow, Cheshire SK9 5AF, United Kingdom.
is necessary to prevent or detect a crime.
Phone: 0303 123 1113 (local rate) or 01625 545 745 (national rate).
5. Marketing and preferences
We may use your personal information to send you marketing by
post, phone, social media, email and text. We only use your personal
information to send you marketing if we have either your permission
or a legitimate interest. If you don’t want to receive personalised
marketing about similar products and services that we think are
relevant to you, please contact us at optmeout@bupa.com or
write to Bupa Data Protection, Willow House, 4 Pine Trees,
Chertsey Lane, Staines-upon-Thames, Middlesex TW18 3DZ
10
Notes
11
Bupa health insurance is provided by:
Bupa Insurance Limited. Registered in England and Wales
No. 3956433. Bupa Insurance limited is authorised by the
Prudential Regulation Authority and regulated by the Financial
Conduct Authority and the Prudential Regulation Authority.
Arranged and administered by:
Bupa Insurance Services Limited, which is authorised and regulated
by the Financial Conduct Authority. Registered in England and
Wales No. 3829851.
Registered office: 1 Angel Court, London EC2R 7HJ
Bupa health trusts are administered by:
Bupa Insurance Services Limited. Registered in England and Wales
No. 3829851.
Registered office: 1 Angel Court, London EC2R 7HJ
© Bupa 2021
bupa.co.uk
BHF 06763
12