Health Insurance Form 


This template contains space for collecting a client’s name, policy number and pre-authorisation details as well as other pertinent insurance related information.

When a client has a private health insurance policy and you are panelled or approved by the insurance company, you may directly bill them. In order to do that, you will need the client’s policy details and authorisation number. This form collects all that information and can be filed and sent to the insurance company.

They may expect regular reports in order to pre authorise further sessions, so this form also specifies what you may share with the insurance company. There is space for your client’s signature and yours.


This document is

  • Customisable and editable
  • Reviewed by lawyers 2020
  • Format updated September 2021

This document is not

  • is not a Third Party Payment form
  • is not a Release of Information
  • is not an Invoice/Receipt template

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