I declare that to the best of my knowledge and belief, the information provided in this claim form is true and complete. I understand and accept that in the event of this claim form being fraudulent in whole as or in part the claim can be invalidated, and I will be liable for any errors in claims arising out of or related to erroneous data provided myself.
I hereby authorize any Doctor of Medicine, hospital or other person who has attended or examined me, to furnish MedNet and my Insurance Company any or all information with respect to my sickness or injury, medical history, consultation, prescriptions, or treatment and copies of all hospital and medical records. This information is required by MedNet and my Insurance Company in order to adjudicate my reimbursement claims.
By submitting the above information I hereby declare that all bank account details provided by me to MedNet are truthful and correct to the best of my knowledge. I hereby authorize MedNet to send my claim(s) reimbursement to the account indicated above by electronic fund transfer method.
Should there be any change in the bank account details provided by me to MedNet, , I acknowledge that it is my responsibility to update it on this website and undertake to do so as soon as reasonably practicable. I agree that MedNet, should not be held responsible or liable for any wrongly transferred claims on the basis that, I have not informed the change in my bank account details to MedNet.
Should a circumstance arise where MedNet credits more monies than the correct claim amount to the account due to duplicate or erroneous electronic fund transfers, I hereby authorize and give my express consent for MedNet to reverse the transactions and withdraw the overpayment. I agree that I will not hold MedNet liable in any way for the recovery of any duplicate or erroneous electronic fund transfers.
MedNet undertakes to pay any associated charges levied by the remitting bank related to electronic fund transfer for claims reimbursement. All charges that may be levied by the member’s bank / or any corresponding bank will be borne by the member.