Medical contact form - Health Care

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What is your question?

What would you like to do?*

Request an insurance certificate
Request individual continuation
Affiliate a family member
Terminate insurance
Change your contact details
Pass on or change your account number
Pass on SEPA mandate / direct debit
Ask for your policy conditions or clarification
Edit or complete your file
Ask a question

Certificate of insurance

I specifically require a certificate for a stay / holiday abroad.

I specifically require a certificate for a stay / holiday abroad.

Country*

Travel period - Start date*

Travel period - End date*

Affiliate a family member

Name family member*

Family member first name Family member surname

Date of birth family member*

Gender family member*

Male
Female
I'd rather not say

Who would you like to affiliate?*

My partner
My child

Affiliate request from ...*

Why would you like to affiliate this family member?

Employed main insured person
Living together / married
Terminate similar insurance

Why would you like to affiliate this family member?

Employed main insured person
Birth / adoption / custody of child / foster child / other
Terminate similar insurance

Date of employment of the principal insured person*

Since what date have you been cohabiting / married?*

Certificate of family composition

Drop files here or

Max. file size: 8 MB.

The files cannot be larger than 8MB

Since which date has this child become part of the family?*

Adoption certificate / appointment of guardian / foster parent with date

Drop files here or

Max. file size: 8 MB.

The files cannot be larger than 8MB

Date of termination of similar insurance?*

Certificate of termination of other insurer with indication of end date

Drop files here or

Max. file size: 8 MB.

The files cannot be larger than 8MB

Terminate insurance for

Name*

First name Surname

Date of birth*

Terminate as from*

Exit reason*

Affiliation other similar insurance
Divorce / no longer cohabiting
No longer entitled to child benefit / 25 years / fiscally dependent

Certificate with start date of affiliation with other insurer

Drop files here or

Max. file size: 8 MB.

The files cannot be larger than 8MB

Date of divorce

Change contact details

What would you like to adjust?*

Address
E-mail address
Phone number

Correction / New address*

Street House number + addition Municipality Postcode Country

To whom does this address apply?*

My family
Myself

Correction / New e-mail address*

New e-mail address * Repeat new e-mail address *

We recommend to use a private e-mail address.

To whom does this e-mail address apply?*

My family
Myself

New phone number*

Transfer / change account number

Which account number would you like to change?*

SEPA mandate / direct debit
Payment of medical expenses
Reimbursement of premium

IBAN*

This is your bank account number that you will find on your bank card and consists of 16 to 27 characters.

BIC

This is a unique identification code of your bank, which you will find on your bank card.

In the name of*

To whom does this new account number apply?*

My family
Myself

Policy conditions / explanation

What would you like to know more about?*

Guarantee of hospitalisation and serious illness
Ambulatory care guarantee
Abroad

Edit or complete your file

What would you like to do?*

Change admission date
My admission has been cancelled
Change hospital
I would like to upload documents

New admission date*

Hospital province*

Hospital*

Upload documents concerning*

my admission
my serious illness file
reimbursement of my medical expenses
my affiliations

Documents*

Drop files here or

Max. file size: 8 MB.

The files cannot be larger than 8MB

Briefly indicate for which admission you want to change / complete this.

I have a question about...

I have a question about*

the Health Care app
my hospitalisation
medical expenses
my settlement note
my premiums and affiliations
a complaint
data protection and privacy
something else

What would you like to know about the app?*

What are you complaining about?

About my settlement
About the medical acceptance of my file
About my premiums and affiliations
Other:

What would you like to report / ask?*

Contact details

Name*

First name Last name

Name of the principal insured person*

First name of the principal insured person Surname of the principal insured person

Name of the hospitalised person*

First name of the hospitalised person Surname of the hospitalised person

Date of birth*

Date of birth of the principal insured person*

Date of birth of the hospitalised person*

Member ID

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

Member ID*

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

Employer

Employer through which you were affiliated to the collective insurance

Admission date

Settlement note ID

Date of settlement note

E-mail*

Your e-mail address Repeat e-mail address

We recommend to use a private e-mail address.

Phone number

Attention: we use these contact details for all plans that you are affiliated with at Vanbreda Risk & Benefits: hospitalisation, outpatient expenses and possible incapacity for work.

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Electronic confirmation

I confirm that my answers are complete and truthful. *

I agree to Vanbreda Risks & Benefits's privacy policy and the rights listed in the policy that I as a data subject can exercise, and to the General Terms and Conditions of Health Care Digital and AssurMiFID code of conduct. 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.). *