To Professional Services rendered during the month……….......…….. 20….

Space for Doctor’s Receipt

The Sum of....................

£

To Account Rendered

£

Total Attendances

(in words) .....................

.............................

Insured Person

Child of the household

FOR OFFICIAL USE .....…..……….. visits

Instructions for the Insured Person are printed overleaf

Date ………………….......….

Voucher No. ..………………

Health Insurance (Jersey) Law 1967

Time Limit within which you must make your claim.

You must claim your refund within 6 calendar months from the end of the month during which the professional services were rendered, otherwise you will lose your benefit.

SOCIAL SECURITY DEPARTMENT,

32 LA MOTTE STREET,

ST. HELIER,

JERSEY, C.I.

You must complete this section.

Forename(s)………………………………

Health Insurance Number

Surname………………………………………

(Block letters please)

I claim medical benefit in respect of medical practitioner’s professional services as shown overleaf.

Signature……………………………………….

Date…………………………………………….

Either:

Bring the receipted white copy of this account together with your Benefits Card to the above address when a cash refund will be given.

Or

Post both copies of this account (with the white copy receipted) to the above address when a refund will be forwarded by cheque. Do not enclose your Benefits Card.

For cash refunds only (to be completed at the time of refund).

Received the sum of £          in respect of medical benefit detailed overleaf.

Signature…………………………………

Address (if not insured person or child of the household).

…………………………………….

…………………………………

RECEIPT

Month

No. of consultations

Gross Fees

Medical Benefit

Net Fees

Out of date for medical benefit

.

.

Accounts rendered

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

To professional services…

.

.

.

To inclusive fee for attendances at confinement and 7 days following

.

.

.

TOTALS

.

.

.

Provided that you are entitled to medical benefit and this account is paid within 6 months of the earliest consultation, you need only pay this net amount.

.

DECLARATION: I certify that the medical services shown above have been provided to me or to a child of my household and I declare that a Jersey Health Insurance Benefits Card is held by me or on my behalf. I authorize the Social Security Department to pay to the doctor the medical benefit in respect of these services.

Signature: …………………………………..

Date: …………………….

IMPORTANT INSTRUCTIONS APPEAR OVERLEAF

SOCIAL SECURITY DEPARTMENT

INSTRUCTIONS FOR SETTLEMENT OF THIS ACCOUNT

This account shows the gross amount of the doctor’s fees, the medical benefit and the net amount which you are required to pay.

You need only pay the net amount if you are covered for medical benefit by a Jersey Health Insurance Benefits Card showing an entitlement date earlier than the date on which the medical services were provided.

Please sign the declaration on the front of this form and send the form together with the appropriate payment to the doctor.

RECEIPTS

If you require a receipt, please send BOTH copies of this account form to the doctor with your payment.

If you do not require a receipt, send only the signed white copy and keep the pink copy.

IF THE NET AMOUNT OF FEES FOR ANY PARTICULAR MONTH IS NOT PAID WITHIN 6 MONTHS YOU MAY LOSE THE MEDICAL BENEFIT FOR THAT MONTH. YOU WILL THEN BECOME LIABLE FOR THE GROSS AMOUNT OF THE FEES.

”