1. I understand this form is for UniMed to review whether my proposed surgery/procedure or treatment is covered under my chosen plan and to reimburse all Healthcare Service Providers.
  2. I certify that all particulars shown in this form are true and correct and authorise UniMed to obtain any further information they may require in relation to this claim.
  3. I acknowledge that my claim needs to be supported by appropriate evidence. This may include but is not limited to itemised accounts showing the name of the relevant provider and the patient concerned. I acknowledge that UniMed may also require a further breakdown showing the cost of items used in surgery, any charges above the usual and customary cost of those items or administration fees charged.
  4. I authorise UniMed to act as my agent for obtaining whatever information it requires about the cost of the healthcare service in order to be satisfied that the cost is usual and customary. This includes, without restriction, to seek information on my behalf from the Healthcare Service Provider.
  5. I acknowledge I have a duty to disclose all information relevant to this claim and to provide additional reports before the date of my surgery/procedure or treatment, should new information arise from the time I sought prior approval.
  6. UniMed may disclose information related to this claim to the Healthcare Service Provider.
  7. I authorise UniMed to negotiate with the Healthcare Service Provider on my behalf to facilitate a reduction in the proposed and/or actual cost of the Healthcare Service where possible. If unable to do so and the charges for the Healthcare Service are above the usual and customary levels, I acknowledge and agree that if I continue with the treatment I will be responsible to the Healthcare Service Provider for the difference between the usual and customary charges and the cost of treatment.
  8. I acknowledge that UniMed’s prior approval is an indication that the healthcare service is covered under my chosen plan but until UniMed issues the claims approval documentation any costs incurred are my own responsibility.