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INSURANCE CLAIMS - PARTICIPANT FORM
Participants First Name
Last name
Claim Number
*
Representative name (If applicable)
Participants DOB
Day
Month
Year
Plan Managers Email
Phone
Address of property to be serviced:
*
Name of your plan manager (If applicable)
Start Date
Day
Month
Year
End Date
Day
Month
Year
How do you pay your Insurance providers?
*
I am self managed and will pay the invoices directly
I have a Plan Manager who pays my providers
Other
What is the best email address for the invoices to be sent to?
*
Invoices will be paid: *Please note we do not work with providers who pay on a monthly payroll.
3-5 days after service
7 days after service
14 days after service
How often would you like us to come?
Once per week
Once a fortnight
Once a month
Other
How long will the service be for?
1 hour express
2 hours
3 hours
4 hours
Other
How many beds/baths does the Participants home have?
*
What’s the preferred method for communicating regarding the participants clean?
Please provide participants diagnosis
Please give some thought to providing us with any specific detail you would like us to know prior to the participants clean
Submit
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