Treatment Guarantee Form - International Healthcare Plans

Submission of a Treatment Guarantee Form is required for the following:

• All in-patient treatments
• Day-care treatment
• Out-patient surgery
• MRI (Magnetic Resonance Imaging) scan. Treatment Guarantee may be required for this test if you would like us to settle the bill directly with the medical provider
• PET (Positron Emission Tomography) and CT-PET scans
  
• Nursing at home or in a convalescent home
• Routine maternity, complications of pregnancy and childbirth (in-patient treatment only)
• Oncology (in-patient and day-care treatment only)
• Occupational therapy (out-patient treatment only)
• Rehabilitation treatment
• Medical evacuation (or repatriation where covered)
• Travel costs of insured family members in the event of an evacuation/repatriation
• Repatriation of mortal remains
• Travel costs of insured family members in the event of the repatriation of mortal remains
• Expenses for one person accompanying an evacuated/repatriated person
• Palliative care and long term care

By following the Treatment Guarantee process, we can ensure that your treatment will be free from financial worries, allowing you to concentrate on getting better.

Treatment Guarantee Form (Editable Word Version)

Treatment Guarantee Form (PDF Version)

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Allianz Worldwide Care offers policy documents in English, German, French, Spanish or Italian. However, for the convenience of our members, we also offer our Treatment Guarantee Form in the following languages:

Arabic Treatment Guarantee Form - (PDF Version)

Bulgarian Treatment Guarantee Form - (PDF Version)

Chinese Treatment Guarantee Form - (PDF Version)

Latvian Treatment Guarantee Form - (PDF Version)

Russian Treatment Guarantee Form - (PDF Version)