Accident/Injury Questionnaire Form | TUH Health Fund

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{"income":0,"selectedFreq":"f","scale":"S","age":"32","age_range":"1","need_cover_hospital":["na"],"need_cover_extras":["na"]}

{"hospital":{"with-dependant":[{"service":["psychiatric"],"with-extras":"0","suggestion":["","",""]},{"service":["weightloss"],"with-extras":"0","suggestion":["","",""]},{"service":["pregnancy-assisted","cataracts"],"with-extras":"0","suggestion":["","",""]},{"service":["pregnancy-assisted"],"with-extras":"0","suggestion":["KJ","",""]},{"service":["cataracts"],"with-extras":"0","suggestion":["RJ","",""]},{"service":["joint"],"with-extras":"0","suggestion":["RJ","KJ",""]},{"service":["heart"],"with-extras":"0","suggestion":["SJ","RJ","KJ"]},{"service":["back-neck-spine"],"with-extras":"0","suggestion":["SJ","RJ","KJ"]},{"service":[],"with-extras":"0","suggestion":["BE","SJ","RJ"]},{"service":[],"with-extras":"1","suggestion":["YNG","BE","SJ"]}],"no-dependant":[{"service":["psychiatric"],"with-extras":"0","suggestion":["GE","",""]},{"service":["weightloss"],"with-extras":"0","suggestion":["GE","",""]},{"service":["pregnancy-assisted","cataracts"],"with-extras":"0","suggestion":["GE","",""]},{"service":["pregnancy-assisted"],"with-extras":"0","suggestion":["KJ","GE",""]},{"service":["cataracts"],"with-extras":"0","suggestion":["RJ","GE",""]},{"service":["joint"],"with-extras":"0","suggestion":["RJ","KJ","GE"]},{"service":["heart"],"with-extras":"0","suggestion":["SJ","RJ","KJ"]},{"service":["back-neck-spine"],"with-extras":"0","suggestion":["SJ","RJ","KJ"]},{"service":[],"with-extras":"0","suggestion":["BE","SJ","RJ"]},{"service":[],"with-extras":"1","suggestion":["YNG","BE","SJ"]}]},"extras":[{"service":["orthotics"],"with-hospital":"0","suggestion":["AN","FAM",""]},{"service":["major-orthodontia"],"with-hospital":"0","suggestion":["AN","FAM","EE"]},{"service":["cpap-hearingaids-health-appliances"],"with-hospital":"0","suggestion":["AN","FAM",""]},{"service":["optical"],"with-hospital":"0","suggestion":["EE","FAM","MR"]},{"service":["massage-myotherapy"],"with-hospital":"0","suggestion":["FAM","60","MR"]},{"service":["osteo-chiro-acupuncture"],"with-hospital":"0","suggestion":["FAM","60","MR"]},{"service":["podiatry"],"with-hospital":"0","suggestion":["FAM","60","MR"]},{"service":[],"with-hospital":"0","suggestion":["60","MR","Y"]},{"service":[],"with-hospital":"1","suggestion":["60","MR","Y"]}]}

/health-cover

Accident/Injury Questionnaire Form

Accident/Injury Questionnaire Form

Please use this form to provide TUH with details relevant to your injury or illness.

Please contact claims.enquiries@tuh.com.au if you experience any issues completing the form or you have other enquiries.

By completing this form, you agree to the TUH Terms and Conditions and declaration listed in the form.

If you'd like to view how we collect and store your information you can view our privacy policy here.

Member/Patient Name *

Member Number *

Date of accident/diagnosis *

Day

Month

Year

Location of accident *

Home

Work (including to and from work)

Other

If location is 'Other', please describe

Please describe the injury/symptoms and how this occurred:

Are you entitled to claim for compensation or damages from a third party (other than TUH) to contribute to payment of medical expenses?

No

Yes

Unsure

Are you claiming worker’s compensation?

Yes

No

If claiming worker's compensation, please provide claim number:

If NOT claiming worker's compensation, please provide reason:

Company/Firm (LAWYER/SOLICITOR INSURER DETAILS)

Contact Person

Email Address

Phone

Postal Address

Reference Number

I declare that all information on this form is true and correct. I authorise TUH to contact any solicitor or any other organisation acting on my behalf, in relation to the accident or illness for assessment of appropriate benefits. *

Yes

I agree to: • promptly repay TUH any benefits paid in relation to the injury/illness for which I have received compensation or damages • keep the fund updated on the status of the claim including any settlement or determination for my third party claim • ensure any benefits paid by TUH relating to this accident/illness are included in the settlement of my third party claim *

Yes

Date of completion *

Day

Month

Year

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In-hosp Psych

Rehab

Back, Neck and Spine

Podiatric Surgery

Hearing devices

Cataracts

Joint replacements

Dialysis

Pregnancy and Birth

Assisted reproductive services

Weight loss surgery including reversal

Insulin Pumps

Pain Management (with device)

Heart and Vascular

Q3H

General Dental

Major Dental

Orthodontics

Optical

Physiotherapy

Chiropractic / Osteopathy

Massage

Acupuncture

Podiatry

Dietician

Speech Therapy

Pharmacy

Hearing Aids / Devices

Orthotics

Psychology

Periodontics

Inlays Onlays Facings

Q3E

I have read the Privacy Policy and accept all terms including the use and disclosure of my personal information.

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We know that choosing a health cover partner is a big decision!

Prefer to have a chat? Book a call back.

Preferred Time *

First Name *

Last Name *

Email Address *

Phone Number *

In-hosp Psych

Rehab

Back, Neck and Spine

Podiatric Surgery

Hearing devices

Cataracts

Joint replacements

Dialysis

Pregnancy and Birth

Assisted reproductive services

Weight loss surgery including reversal

Insulin Pumps

Pain Management (with device)

Heart and Vascular

Q3H

General Dental

Major Dental

Orthodontics

Optical

Physiotherapy

Chiropractic / Osteopathy

Massage

Acupuncture

Podiatry

Dietician

Speech Therapy

Pharmacy

Hearing Aids / Devices

Orthotics

Psychology

Periodontics

Inlays Onlays Facings

Q3E

I have read the Privacy Policy and accept all terms including the use and disclosure of my personal information.

Privacy policy *

Your selected hospital inclusions

I want hospital cover for:

Hospital psychiatric care

Weight loss surgery

Pregnancy & birth or Assisted reproduction

Cataracts

Joint replacement

Heart and vascular system

Back, neck and spine

No thanks, I'm good!

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Your selected extras inclusions

I want extras cover for:

Orthotics

Hearing aids or health aids

Major dental or orthodontics

Optical

Massage or Myotherapy

Osteo, Chiro and/or acupuncture

Podiatry

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In-hosp Psych

Rehab

Back, Neck and Spine

Podiatric Surgery

Hearing devices

Cataracts

Joint replacements

Dialysis

Pregnancy and Birth

Assisted reproductive services

Weight loss surgery including reversal

Insulin Pumps

Pain Management (with device)

Heart and Vascular

Q3H

General Dental

Major Dental

Orthodontics

Optical

Physiotherapy

Chiropractic / Osteopathy

Massage

Acupuncture

Podiatry

Dietician

Speech Therapy

Pharmacy

Hearing Aids / Devices

Orthotics

Psychology

Periodontics

Inlays Onlays Facings

Q3E

status

reason

{"abdSkus":["YNG","BE","BF","CE","CF","KJ","KF","RJ","RF"],"underFortySkus":[""],"underFortySkusDep":["YNG"],"overFortySkus":["YNG"],"hospitalForceWithExtras":["GE"],"april1MessageProductGuides":""}