MRI/CT/PET Scan Form

Health Plan

Complete this form if you have Basic or Comprehensive cover and require a CT, MRI or PET Scan.
Upon receipt of this form Police Health Plan will confirm cover then send confirmation to the radiology clinic.


and you need a scan to determine whether you need surgery, you will need to pay for the scan.
If the scan leads to surgery and Health Plan approves cover for the procedure, you can be reimbursed for the costs.


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

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

To edit the 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 Forms can be submitted to Police Health Plan:

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

By email: Attach your completed form to an email. Please don't embed the PDF or JPG in the email. 

The scanned JPG or PDF must be easily readable or processing your 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 into your email as this will delay processing.