7/27/2019 Formatos Axa Extranjeros

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122 S. Michigan Suite 1100 Chicago, IL 60603 U.S.A.

Tel: (312) 935-3712 / Fax: (312) 803 2754 / Email: ati-usa@axa-assistance.us

FACSIMILE TRANSMISSION COVER SHEET

Please complete and fax to (312) 803 2754 or e-mail to: ati-usa@axa-assistance.us

To : (name of hospital) Fax No:Attn: (name of patient) Date:From: AXA Assistance U.S.A. Chicago ref:Re: Previous Medical History check Pages:

Dear Mr/Mrs ______________________

We are the assistance company working on behalf of your travel insurance.

In order for us to proceed with your claim we may need to liaise with your GeneralPractitioner regarding your past medical history. To enable us to do this we requireyour written/signed consent. We would therefore be grateful if you could complete(where relevant) and sign the attached Release of Information (ROI) form and return itto us by fax at your earliest convenience.

We stress that this is standard procedure in all medical cases, and we thank you inadvance for your cooperation.

Kind regards,

AXA Assistance U.S.A.

This message is intended only for the use of the individual or company to which it is addressed and may containinformation that is privileged and confidential. If you have received this communication in error, please notify usimmediately by telephone or fax. Thank you.

7/27/2019 Formatos Axa Extranjeros

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RELEASE OF MEDICAL INFORMATION AND LOCAL GP DETAILS

CONFIDENTIAL

PATIENT NAME : ________________________________________________________

DATE OF BIRTH: ________________________________________________________

AXA REFERENCE: ________________________________________________________

HOME ADDRESS: ________________________________________________________

________________________________________________________

PLEASE READ THIS INFORMATION CAREFULLY - THIS STATEMENT EXPLAINS YOUR RIGHTSUNDER THE ACCESS TO MEDICAL RECORDS ACT 1988 (UK)

1. Your written/signed consent is required before we can request the medical information necessary forus to make a decision relating to proceeding further with your claim.

2. You are entitled to see any report written by your doctor before it is sent to us.

3. If you disagree with the contents of the report, or think it is misleading, you have the right to ask yourdoctor to change it or withhold it.

4. NB - If however, information is withheld or changed, we, acting on behalf of your insurers have theright to know what information has been withheld or changed.

5. Your doctor may withhold all or part of his/her report from you if he/she feels that it would be in yourbest interest or that of others, that he/she does so.================================================================PATIENT STATEMENT:

I confirm that I have read the above and agree to my doctor releasing the required medicalinformation to the medical advisors of AXA Assistance and to the appointed officers/agents ofyour insurance company. (a signed facsimile or photocopy of this document will constitute suchauthority).

I confirm that I do / do not wish to see the report before it is sent. (Circle one)

I confirm that the treating doctor/general practitioner is the person named on the bottom of this form.

I further confirm that I am willing to pay my General Practitioners reasonable fees (BMA rates) forproviding this information in accordance with the terms and conditions of my insurance policy and it is myresponsibility to contact my General Practitioner in this regard.

GPs NAME AND ADDRESS: ...........................................................................................................................................................................................................................................................................................

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

Tel: ......................................................................................

SIGNED: ...................................................................... DATE: .....................................