Kostenformulier test - Health Care

Personal data patient

First name*

Last name*

Telephone number

Member ID

E-mail*

Enter Email Confirm Email

We recommend to use a private e-mail address.

Date of birth*

Do we already have a bank account number in your file for the reimbursement of these medical costs?*

Yes
No

We will reimburse these costs to the known account number.

Bank details

IBAN*

This is your bank account number that you will find on your bank card and consists of 16 to 27 characters.

BIC

This is a unique identification code of your bank, which you will find on your bank card.

In the name of

First Last

These bank details will be used by default for this patient for all future expenses.

Which costs would you like to submit?

In order to guarantee a swift treatment of your costs, we can give you the following tips:

For outpatient medical treatments and consultations (specialist, physiotherapist, examination, etc.) you provide us preferably with the separate receipts of the health insurance fund. In case you no longer receive these receipts from your health insurance fund, you can send us an overview list from your health insurance fund with the provided medical treatments only. General overview lists with other expenses will not be accepted.
For pharmaceutical costs you provide us with the separate BVAC certificates you receive from your pharmacist. Overview lists from the pharmacist will no longer be accepted.
For dental care (not orthodontics) you provide us with the tooth numbers of the teeth that have been treated as well as the amount charged per tooth. For a dental prosthesis, you provide us with a detail of the type of dental prosthesis (removable or not) as well as the correct nomenclature numbers. You can always contact your dentist for this additional information.
Always provide us with the complete bill, with all the pages in the right order and perfectly legible. Do not join several documents in one picture or scan.

Outpatient expenses (this option should only be used for expenses NOT related to a hospitalisation or serious illness)
Hospitalisation (this option should only be used for expenses related to a hospitalisation)
Serious illness (only to be used when expenses are related to a serious illness)

Attachment(s):*

Drop files here or

Max. file size: 8 MB.

Attention: Total size of uploaded files is limited to 8 MB.

Please be sure to keep the original of the (scanned) copy and immediately make it available to Vanbreda Risk & Benefits if so requested. You hereby confirm that you will only request the reimbursement of these costs via Vanbreda Risk & Benefits and will immediately inform Vanbreda Risk & Benefits if you receive a reimbursement of these costs in any other way. In that case you are not entitled to a reimbursement via Vanbreda Risk & Benefits.

Hidden

Electronic confirmation

I confirm that my answers are complete and truthful. *

I agree to Vanbreda Risks & Benefits's privacy policy and the rights listed in the policy that I as a data subject can exercise. This data, including my health data, may be processed by Vanbreda Risk & Benefits for the purposes of customer service, accepting risks, managing contracts and claims, making insurance related payments, and the proper functioning of their services. If it is required to execute this agreement or if they obliged to do so by law, Vanbreda Risk & Benefits may forward my personal data to third parties (insurers, experts, monitoring doctors, etc.). *