Health Plan - Surgical Approval Request Form

Health Plan
  • If you need surgery you must complete this form.
  • If you require surgery with a GP, you do not need surgical prior approval.
    If you need surgery with a GP, you can pay for the procedure and claim back up to $750 per visit.
    Simply complete a Medical claim form and attach the full invoice.

All Health Plan surgical claims must be pre-approved prior to surgery. Complete this form as soon as surgery has been decided necessary, for pre-approval of your surgical claim.

If your surgery is scheduled in the next 10 days, your request will be given urgent priority. Please email (or fax) the request form to us to ensure faster processing.

For urgent cases or to have a form posted contact our Member Services Team.

You can print a blank approval request form and complete, or edit the form online.

Make sure you have Adobe Acrobat Reader downloaded (not Adobe Preview). Download Adobe Acrobat Reader

To edit the claim form online please

1. Open the 'editable online' pdf  using either Firefox or Internet Explorer internet browsers for optimal results.

2. SAVE it to your computer before you complete the form.

3. Complete the form and save again, then send the completed form to us (see details below).

Completed Surgical Approval Request Forms can be submitted to Police Health Plan:

By post: Claims submitted by post must include letter of referral and an estimate of the costs involved.

Send to: Police Health Plan Ltd, PO Box 12344, Wellington 6144.

By email: Attach your completed claim form to an email, along with your letter of referral and an estimate of the costs involved, which have been scanned as a JPG or PDF file. Please don't embed these in the email. If you are emailing your claim form, you don't need to post it.

The scanned JPG or PDF must be easily readable or processing your surgical claim may be delayed.


When emailing forms, documents or pictures:
Please use the attachment function to attach your jpeg, png or PDF to your email. Do not insert them into your email as this will delay processing.

If you are emailing your claim form, you don't need to post it.