Claim Reimbursement


This form can be completed if you have paid for treatment and would like to claim back the eligible costs

If the amount of your claim exceeds US$500 (or equivalent in another currency) please ask your physician to complete section B of the claim form which can be found here. This will then need to be uploaded with this form or emailed to us later at

Your Personal Details

Please complete the information requested and include supporting information via the document upload function

Details of the condition being treated