PAYMENT VOUCHER
Deakin University Health Plan
Claim for reimbursement of hospital excess
Creditor No:
Date:
Section 1 – Employee Details
Surname:
Given Name:
Address:
Postcode:
Email:
Phone:
HCF Mem. No.
Section 2 – Claim Details
Name of person hospitalised:
Relationship to employee:
HCF Claim No. (if known):
Hospital to which excess was paid:
Date of receipt:
/
/
Amount of claim:
$
Admission Date:
/
/
Important:
To avoid any delay in payment please ensure that the original receipt issued by the hospital for the payment
of the excess together with a photocopy of your HCF membership card is attached to this form. Please do not
lodge you claim until after your hospital admission. The receipt must clearly state that the payment was for a
hospital excess. You should retain a photocopy of the hospital receipt for your records.
Section 3 - Payment Details
The excess refund payment will be paid by electronic funds transfer (EFT) to the account you specify in this
section.
Financial Institution:
BSB:
Account Name:
Account No.:
Section 5 - Declaration
I declare the above details to be true and correct and request reimbursement of the hospital excess paid
by me. I undertake to furnish a copy of the Claims Statement issued by HCF upon request.
Employee Signature:
Date:
Contact Name:
Login:
Ext:
Authorised By:
Login:
Date:
/
/
/
/
Account Code”
BC
9
9
0
Activity
1
0
0
0
0
Account
0
9
3
7
FS
5
0
Entity
0
0
HRD Section
Was the claimant an eligible member of the scheme at the time of the
hospital admission?
Is the original ‘excess’ receipt attached to the claim form?
Has a copy been forwarded to the Excess Refund Account trustee
Finance Section
Processed By:
Request Number:
Amount
1
Authorised By:
Payment Number:
:
 Yes
 Yes
 Yes
 No
 No
 No