Declaration Serious illness

Complete this form to open your ‘serious illness’ file. To process your file, we need a report from your doctor with the diagnosis, and the followed and planned treatments.
If you don't have a medical report yet, we ask you to wait with your declaration.

Patient records

Patient name*

Patient first name Patient last name

Patient date of birth*

Member ID

Date of diagnosis

Specify the exact day of diagnose or the first day of the month in which your were diagnosed.

Which illness do you suffer from?*

Which kind of cancer do you have?*

Condition not in list

Not found in the list ? Please describe the diagnosis as detailed as possible below.

Additional info (diagnosis/treatment)*

Medical report

Drag your medical report below, drawn up by your treating doctor, stating your diagnosis and the followed and planned treatments.The files cannot be larger than 8MB.

Drop files here or

Max. file size: 8 MB.

Contact details

Name*

First name * Surname *

Date of birth*

Member ID

You can find this on your certificate of affiliation, settlement invoice or any personal communication of us.

E-mail address*

Your e-mailaddress Repeat e-mailaddress

We recommend to use a private e-mail address.

Hidden

Electronic confirmation

I confirm that the answers are complete and true.*

I confirm that the answers are complete and true.

Ik nam kennis van hget privacybeleid ...*

I agree to Vanbreda Risks & Benefits's privacy policy and the rights listed in the policy that I as a data subject can exercise. This data, including my health data, may be processed by Vanbreda Risk & Benefits for the purposes of customer service, accepting risks, managing contracts and claims, making insurance related payments, and the proper functioning of their services. If it is required to execute this agreement or if they obliged to do so by law, Vanbreda Risk & Benefits may forward my personal data to third parties (insurers, experts, monitoring doctors, etc.). *