122 S. Michigan Suite 1100 Chicago, IL 60603 U.S.A.

Tel: (312) 935-3712 / Fax: (312) 803 2754 / Email: ati-usa@axa-assistance.us

FACSIMILE TRANSMISSION COVER SHEET

Please complete and fax to (312) 803 2754 or e-mail to: ati-usa@axa-assistance.us
To : Attn: From: Re: (name of hospital) (name of patient) AXA Assistance U.S.A. Previous Medical History check Fax No: Date: Chicago ref: Pages:

Dear Mr/Mrs ______________________ We are the assistance company working on behalf of your travel insurance. In order for us to proceed with your claim we may need to liaise with your General Practitioner regarding your past medical history. To enable us to do this we require your written/signed consent. We would therefore be grateful if you could complete (where relevant) and sign the attached Release of Information (ROI) form and return it to us by fax at your earliest convenience. We stress that this is standard procedure in all medical cases, and we thank you in advance for your cooperation. Kind regards,

AXA Assistance U.S.A.

This message is intended only for the use of the individual or company to which it is addressed and may contain information that is privileged and confidential. If you have received this communication in error, please notify us immediately by telephone or fax. Thank you.

RELEASE OF MEDICAL INFORMATION AND LOCAL GP DETAILS

CONFIDENTIAL PATIENT NAME : ________________________________________________________ DATE OF BIRTH: ________________________________________________________ AXA REFERENCE: ________________________________________________________ HOME ADDRESS: ________________________________________________________ ________________________________________________________ PLEASE READ THIS INFORMATION CAREFULLY - THIS STATEMENT EXPLAINS YOUR RIGHTS UNDER THE ACCESS TO MEDICAL RECORDS ACT 1988 (UK) 1. Your written/signed consent is required before we can request the medical information necessary for us to make a decision relating to proceeding further with your claim. 2. You are entitled to see any report written by your doctor before it is sent to us. 3. If you disagree with the contents of the report, or think it is misleading, you have the right to ask your doctor to change it or withhold it. 4. NB - If however, information is withheld or changed, we, acting on behalf of your insurers have the right to know what information has been withheld or changed. 5. Your doctor may withhold all or part of his/her report from you if he/she feels that it would be in your best interest or that of others, that he/she does so. ================================================================ PATIENT STATEMENT: I confirm that I have read the above and agree to my doctor releasing the required medical information to the medical advisors of AXA Assistance and to the appointed officers/agents of your insurance company. (a signed facsimile or photocopy of this document will constitute such authority). I confirm that I do / do not wish to see the report before it is sent. (Circle one) I confirm that the treating doctor/general practitioner is the person named on the bottom of this form. I further confirm that I am willing to pay my General Practitioners reasonable fees (BMA rates) for providing this information in accordance with the terms and conditions of my insurance policy and it is my responsibility to contact my General Practitioner in this regard. GPs NAME AND ADDRESS: ................................................................................................................... ........................................................................................................................................................................ ........................................................................................................................................................................ Tel: ...................................................................................... SIGNED: ...................................................................... DATE: .....................................