CLAIMFORM ILLNESS/CONDITION HEALTH INSURANCE - PSYCHOLOGIST Danica Pension Parallelvej 17 DK-2800 Kgs. Lyngby Denmark Telephone +45 70 11 25 25 Policy Name CPR. Address Tel. Mobile To be filled in by the insured. All questions must be answered. Your insurance cover is detailed in your statement of cover and in the insurance conditions. 1. Which illness/condition or symptoms do you have? What has given rise to your need for psychological help? 2. Is your illness/condition work-related? The definition of work-related illness is whether there is a connection between your performance of work and the illness/condition you have Eg. associated with layoffs, counseling to employees who have been victims of robbery or stress because of too much work. 3. Is your illness/condition/symptoms the result of an accident? Date of accident: 4. When did you first notice any symptoms of the illness/condition? Date: DAN90423_ENG 2013.09 5. Have you consulted your usual doctor because of the illness/condition/symptoms? Date of first visit: Page 1 of 5
6. Who is your usual doctor? Navn: Adresse: 7. Have you previously needed psychological or medical help for psychological reasons? If yes: What gave rise to your previous need for psychological or medical help? When: Who treated you? Name: Address: 8. Do any other illnesses or conditions influence your current condition? Which: 9. Have you been referred to psychological services by the Danish Health Care Service? If no: Has your own doctor recommended that you seek psychological help? 10. Are you a member of the health insurance company danmark? Which group: 11. Have you reported the illness/condition under nother insurance or is it covered by another insurance? Which company: Policy number: Declaration I declare that all questions have been answered to the best of my knowledge and that I have not withheld any information which might be relevant to a decision on whether the conditions laid out in the insurance policy have been fulfilled. Date CPR. Signature Page 2 of 5
CONSENT INSURANCE EVENT FP 602 Consent to obtaining and passing on information the insurance claim Danica Pension Parallelvej 17 DK-2800 Kgs. Lyngby Denmark Phone +45 70 25 02 03 Why we need your consent Pursuant to the Danish Insurance Contract Act, you must provide your insurance company with all accessible and relevant information when filing a claim. Therefore, you are under an obligation to disclose to Danica Pension all the information that may affect the assessment of your claim and the amount of compensation payable to you. Payment of compensation The Act also stipulates that you are not entitled to the payment of any compensation under your insurance until two weeks after Danica Pension s receipt of your claim. The information stated in the claim is necessary for us to assess your case and determine how much compensation you may be entitled to. Your doctor and others may pass on information about your health Under the Danish Health Act, your doctor may, subject to your consent, pass on your health details, information about other personal matters and other confidential information. Other legislation also allows public authorities and insurance companies, etc., to pass on information about you on condition that you have given your consent. You may withdraw your consent at any time Your consent is in force for a year from issue. A copy of your consent will be submitted to all parties from whom Danica Pension requests information. You can always withdraw your consent if you no longer wish it to be in force. You will be notified each time Danica Pension obtains information You will be notified each time Danica Pension obtains specific information about you. The notice will state why we requested the information, the type of information we have requested, the precise period in which we are interested and from whom we have requested information. Consent I give my consent to Danica Pension s obtaining, using and passing on personal information about me which Danica Pension deems necessary to reach a decision on my claim. The persons or bodies from whom Danica Pension wishes to obtain information may pass on the information requested by Danica Pension. Persons and bodies from whom Danica Pension may obtain information or to whom information may be passed on Hospitals, doctors and other authorised health personnel. Public authorities, such as local authorities, the police and the Danish National Board of Industrial Injuries. Insurance companies, pension funds, the Danish Centre for Health & Insurance and the Patient Compensation Association. Business partners working for Danica Pension in connection with the assessment of my claim. My employer (exchange of certain information only). Types of information that may be passed on Health information, including information about specific illnesses and contacts to health services. Information about social, financial and other matters. To my employer: Name, CPR., and the fact that I have filed an insurance claim. From my employer: Working hours, sickness absence, salary and special working conditions. The consent covers information about events which occur up to the time when Danica Pension has reached a decision on my claim. Time limit and notification The consent is in force for one year. I may withdraw my consent at any time or have any incorrect or misleading information about me corrected or deleted. The persons involved in my case will be informed that I have given this consent. I will be notified each time Danica Pension obtains information about me. I will also be informed of the reason for obtaining the information, the nature of the information obtained and passed on and for which period and from whom the information is obtained. DAN90687_ENG 2014.05 Date CPR. Signature This declaration of consent was prepared by the Danish Medical Association and the Danish Insurance association Page 3 of 5
FP 710 SUNDHEDSFORSIKRINGSATTEST Danica Pension Parallelvej 17 2800 Kgs. Lyngby Danmark Telefon 70 25 02 03 Til lægen: Denne attest må kun udfyldes på foranledning af det pensions- eller forsikringsselskab, hvor den forsikrede er kunde. Lægen honoreres således kun, hvis selskabet har bedt lægen om at udfylde den. Attesten er i udgangspunktet en fremmødeattest. Hvis selskabet eller patienten ønsker, at lægen skal udfylde attesten uden, at patienten er til stede imens, skal patienten afgive samtykke hertil. Navn CPR-nr. Attesten er udfyldt vedrørende: Udfyldes af den undersøgende læge 1 Hvor længe har du været patientens læge? 2 Hvilke symptomer har patienten og hvornår startede de? Dato for første symptom: 3 Hvornår undersøgte du patienten for symptomerne første gang? Foreligger der en diagnose på tilstanden? Hvis, hvilken diagnose (gerne på latin): Er sygdommen kronisk? 4 Hvornår blev diagnosen stillet? Har du henvist patienten til speciallæge, sygehus eller anden behandler, fx psykolog, fysioterapeut, diætist? Hvis, vedlæg venligst lægehenvisning. a. Har du henvist patienten til billeddiagnostiske undersøgelser? Hvis, vedlæg venligst lægehenvisning. b. Ved psykologhjælp: Er patienten henvist via den offentlige sygesikring? Hvis, vedlæg venligst lægehenvisning. Angiv den udløsende årsag til, at der er behov for psykologhjælp: Hvis, kan du anbefale psykologhjælp? c. Ved behandling hos diætist: Højde Vægt: Angiv indikationen for behandlingen: d. Ved kiropraktorbehandling: Kan du anbefale kiropraktorbehandling? 5 6 Har patienten dig bekendt været behandlet/ undersøgt for samme symptomer, sygdom eller skade før? Skønner du, at tidligere symptomer, sygdomme eller andre forhold, herunder graviditet, har haft nogen form for indflydelse på nuværende symptomer/sygdom eller forværret dens følger? Hvis, hvornår: Hvis, hvilken indflydelse på tilstanden? DAN90690 2014.03 Hvornår debuterede symptomerne/sygdommen? Der kan evt. vedlægges relevante udskrivningsbreve og undersøgelsesresultater m.v. Medmindre andet er anført, er jeg indforstået med, at selskabet kan udlevere en kopi af attesten til patienten eller dennes repræsentant. Vend Side 4 af 5
Denne attest er udfærdiget af mig i overensstemmelse med mine optegnelser, mit kendskab til patienten, mine spørgsmål til patienten og min undersøgelse. Dato Lægens underskrift Attesten sendes i lukket kuvert mærket Attest til: Att.: Sundhedsteamet Parallelvej 17 2800 Kgs. Lyngby Nøjagtig adresse (stempel): CPR-nr./CVR-nr.: Giro/Bank Regnr. Kontonr.: Betaling kan ske til NemKonto for det angivne CPR/CVR/SE-nr. ID-nr. 04.10.01.01. Attesten er godkendt af Den Almindelige Danske Lægeforenings attestudvalg og honoreres af forsikringsselskabet straks efter indsendelse af regning på beløb svarende til den gældende takst ifølge overenskomst med Lægeforeningen. Eftertryk/efterligning ikke tilladt. Side 5 af 5