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CLAIM INFORMATION

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DIAGNOSIS

TERMS & CONDITIONS

I hereby authorize, agree and consent to:
1. Insurer and Fullerton Healthcare Group to request to any hospital, physician, person or organization, all information with respect to any illness, injury, medical history, and copies of all hospital or medical records concerning myself at any time and authorize the prior mentioned organizations to disclose all such information to Insurer and Fullerton Healthcare Group
2. Insurer and Fullerton Healthcare Group collecting, using, and/or disclosing my personal data for claims processing and such other purposes ancillary or related to the administering of my insurance coverage and claims adjudication.
I agree that the Insurer and Fullerton Healhcare Group and my Employer reserve the right to recover any outstanding amount should my total medical expenses exceed the policy coverage and/or is not covered under the policy.
I hereby declare that all the information, above statements and answers including any attachments related to it are true and complete. I have not withheld any material fact from Insurer, Fullerton and my Employer.
I agree that a photocopy of this authorization shall be considered as effective and valid as the original.
I agree that Insurer and Fullerton Healthcare Group reserve the right to request for my original invoices for audit purpose. I will retain the original invoices for a period of 12 months from the incurred date, should there be an audit exercise on my claims.
I will not be claiming from other insurers unless the total cost exceeds the benefit amount.

Declaration and Authorisation(to be accepted by the Employee and Patient/Guardian)

persons and organisations, whether within or outside Singaporem including but not limited to medical sources, hospitals, doctors other healthcare professionals, laboratories, regulator, dispute resolution centres and the insurers, their associated persons/organisations, my/our or the insured person’s empployers or financial service providers, or their thrid party service associated persons/organisations, its and their thrid party serviceproviders and its and their representatives, whether within or outside Singapore any information concerning the policy owener and the insured person(s) at any time, including akk oersibak data and information, medical information, medical history, consultation history and notes, prescriptions, treatmeants, descriptions of medical services rendered, and any employment and financial information, including the taking of copies of such records (collectively "Personal Data"), relevant for the purpose (defined below);
the Insurer and Fullerton Healthcare Group sharing the scope of sub-clause(a) above, along with any of the Personal Data, with any relevant third parties to procure their disclosure and the release of additional relevant Personal Data for the Purpose;
the Insurer and Fullerton Healthcare Group, including their approved medical examiners or laboratories, performing any necessary medical assessments and examinations and test to determine, assess and evaluate the health of the insured person(s)
the Insurer and Fullerton Healthcare Group collecting, using, disclosing, storing, retaining and/or processing (collectively,”Using”/”Use”)the Personal Data for the Purpose, and
waive any right (on my own behalf and on behalf of the insured person(s) where applicable, in respect of which I/we represent and warrant that the insered person(s) have granted me/us authority to so waive) to bring a claim of any nature against anu of Insurer and Fullerton Healthcare Group in respect of any above-mentioned Use and/or any Use of any Personal Data for the Purpose. Where I/we are not the insured person, I/we represent and warrant that I/we have obtained the consent of the inserd person(s), except to the extent such consent is not required under relevant laws: (i) to collect their Personal Data; (ii) to disclose to their Personal Data to the Insurer and Fullerton Healthcare Group; (iii) for the Insurer and Fullerton Healthcare Group and Third Parties to Use any of their Personal Data in the manner and for the purposes described in this Clause. I/we hereby agree to indemnify the Insurer and Fullerton Healthcare Group for all the losses and the damages that Insurer and Fullerton Healthcare Group and suffer in the event that I/we are in breach of any representation and warranty provided by me/us herein. In this Clause, “Purpose” means any of the purposes described in the Insurer’s personal data policies and Fullerton Healthcare Group Data Policy, including but not limited to processing of this form, to provide subsequent advice or services to me/us or the insured person in relation to any existing or future policy/policies/programmes that I/we may hold/participate with Insurer and Fullerton Healthcare Group. This authorisation shall bind my/our successors and assignees, and remain valid, not withstanding death, irrespective of wether or not my/our Application/form is accepted by Insurer and Fullerton Healthcare Group. A photocopy of this authorisation shall be valid and effective as the original.

Disclaimer

Aon care is a medical network administering insurance and policies arranged by Aon Singapore Pte, Ltd("Aon") acting as an insurance broker. Aon is not and insurer and does not guarantee the acceptance, application or availability of insurance. The content of this form has been compiled by Fullerton Healthcare Group Pte Ltd and is subject to the terms, conditions and exclusions of the regualted insurer’s policy wording which may change form time to time. Refer to the relevant policy document for complete and most up to date details. Neither Aon nor any Aon Group entity, will be held liable for the contents of this form, its existence or any representations made in its connection. For further information on Aon Care or related insurance, products, please contact a representative of Aon.

I/We, hereby authorize, agree and content to the above statements.