Application form for Prior Park College

In order for your child to be covered it is your responsibility to complete this application form and submit it to AXA Health. Failure to submit the form in sufficient time may mean your child might not be covered from the start of this term. We require a separate completed application form for each child.

For further information on the Pupils' Healthcare Scheme please call Marsh Limited Education Practice (Scheme intermediary) on 01444 335174. Lines are open Monday to Friday 9am to 5pm.

Fields marked with a * are required.

School details

This application is for Prior Park College

Prior Park College
Ralph Allen Drive
Combe Down, Bath
Avon
BA2 5AH

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If you believe your school details are incorrect, please contact your school directly. You can find details in your school information pack.

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Child details

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Your child's join date can be today's date if you are applying within the current joining window. If not available, you may select from the first day of either of the next two terms.

Please be advised that we will not backdate the enrolment for any pupil outside of these dates.

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To join the Pupils Healthcare Scheme on the 1st September 2024, the application will need to be made through a new online form, due to this version being decommissioned.

Details of the new online application form will be supplied by your child’s school once the scheme renewal has been confirmed.

Applications to join the scheme on the 1st September 2024 will be open from the 1st June 2024. The deadline for applications is the 30th September 2024.

Please contact your school scheme administrator for further information.

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Parent / Legal guardian details

Please note that the parent/legal guardian is not entitled to cover under this plan.

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So that we can be sure we're speaking to the right person, please provide a memorable date that will identify you when you call.

Please provide a hint/reminder that we can ask you, to help remember your chosen date if you forget - e.g. your birthday or wedding day.

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Appointment of an Authorised Guardian

To assist with the claims administration process, parents of a pupil under 16, or a pupil 16 and over, can appoint an Authorised Guardian or the school as an alternative contact to manage claims on behalf of the parent or pupil.

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Appointing an Authorised Guardian

When dealing with an Authorised Guardian AXA Health will be able to:

  • Take details of a claim including health and medical information.
  • Disclose health and medical information that it may have obtained from healthcare providers.
  • Dependant on the medical practitioner's policies, for children under 16 obtain medical practitioner's notes and reports based on the Authorised Guardian's consent.

An Authorised Guardian will not be able to:

  • Cancel your child's cover.
  • Amend your child's cover.

If you or your child aged 16 or over wish to appoint an Authorised Guardian please complete the relevant part of the application form before returning it to the school.

Please ensure you advise the Authorised Guardian you will share their contact details with AXA Health, the scheme intermediary, Marsh and the school.

Generally AXA Health will not deal directly with any pupil under 16 years of age. Any contact regarding claims should be made by the parent/legal guardian who is named on the application form, or the Authorised Guardian.

Very rarely AXA Health may deal directly with a pupil less than 16 years of age, but only on advice from their doctor that the doctor considers them competent to make their own healthcare decisions and is likewise not looking to deal with an adult on their behalf.

AXA Health will speak with pupils 16 years or over on the legal presumption that they have the capacity to make their own decisions about their healthcare, unless we have cause to believe this may not be the case.

When a child reaches the age of 16 the authorisation from the parent will expire and AXA Health will need the child to provide authorisation if the child wishes to appoint an Authorised Guardian.

If you choose an Authorised guardian other than the school it should be someone who will be readily available to communicate with AXA Health and support your child. If you have already appointed a guardian who will deal with the school on other matters because you are out of the UK, ideally you would choose this person.

By appointing an Authorised Guardian you consent to that person discussing claims for your child with AXA Health.

You also consent to AXA Health discussing all aspects of claims, including information regarding the physical or mental health or condition of your child, with that person. You also appoint the Authorised Guardian to act in your place in giving consent, if necessary, to:

  • AXA Health obtaining information about your child's mental or physical health or condition from your child's healthcare practitioners;
  • Your child's healthcare practitioners disclosing to AXA Health; information about your child's mental or physical health or condition; and
  • Your child's healthcare practitioners providing AXA Health with copies of information or documents held in your child's health record to the extent AXA Health deem necessary to enable them to assess any claim.
  • Make shortfall/excess payments on your child's behalf.
  • Receive payments on behalf of your child from AXA Health e.g. for cash payments if your child has in-patient treatment under the NHS.

If you appoint an Authorised Guardian and at any point you wish to withdraw your appointment or there is a particular claim that you do not want your chosen Authorised Guardian to deal with, it is your responsibility to make sure that AXA Health know this.

An Authorised Guardian is different to a Legal Guardian in this process and must be over 21.

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So that we can be sure we're speaking to the right person, please provide a memorable date that will identify the Authorised Guardian when they call.

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Please provide a hint/reminder that we can ask the Authorised Guardian, to help remember their chosen date if they forget - e.g. the Authorised Guardian's birthday or wedding date.

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Declaration

Important:

Please read this declaration carefully before signing and dating it. We recommend that you keep a record of all information you supply to us in connection with your child's membership, including letters.

  • I confirm that all information provided in this application is true and complete to the best of my knowledge and belief.
  • I understand that I, the parent/legal guardian, am not entitled to any benefit under this plan.
  • I declare that I have informed all persons 16 or over and if applicable the Authorised Guardian to be included on this application that their details will be disclosed to AXA, Marsh and the school, in order to process this application and I have personally confirmed with them that the information regarding them is complete and correct.
  • I understand it is my responsibility to ensure any person 16 or over has read the contents of this form.
  • I have read the Data Protection statement below and have shown this to my child, if over 16.
  • I understand that if I wish to cancel my child's cover before the start date I can do so by notifying the child's school.
  • I understand that I have the option of cancelling my child's cover under the Pupil's Healthcare Scheme and receiving a refund, as long as I do so in writing to the school within 21 days of cover starting and no claims have been paid in respect of that child. Any refund that is made during the cancellation period will come from the school. If a claim is made within the 21 day cancellation period and the parent/legal guardian still wishes to cancel, then the parent/legal guardian is liable for the premiums for that term. During the cover period I understand that if I wish to end my child's cover under the scheme, I can do so with effect from the end of the current term and that no refund will be paid to me.
  • I confirm that I am the person with whom parental responsibility for the child named in this application form (and on any separate sheet) lies.
  • I confirm that if I have named an Authorised Guardian I have given my explicit consent for the Authorised Guardian to represent me and my child should the Authorised Guardian need to make a claim for my child under this plan.
  • I understand that cover will commence from the start of the next school term provided that my child's school pays the premiums to Marsh and this form is received by the school in sufficient time. I understand cover will end if my child's school does not pay premiums to Marsh.

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Please confirm that the child gives their explicit consent for you, the parent or the legal guardian, to represent them - and, if applicable, for the Authorised Guardian or the school to represent them, as set out in the 'Appointing an Authorised Guardian' section of this form.

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Data Protection

Important:

AXA PPP healthcare Limited, Marsh and any reinsurer will deal with all personal information in the strictest confidence. We will comply with the provisions of data protection legislation.

We use other companies to do some of our work for us and to run and improve our computer systems. Some of these are in countries outside the European Economic Area (EEA), including some where the laws protecting personal information may not be as strong as in the EEA. We take steps to ensure that any companies and intermediaries that we use give an appropriate level of protection. In this Data Protection section 'we' means AXA Health. 'You' means the parent/legal guardian named in section 1.

How we will use your information

We will process information about you, any Authorised Guardian and your child that may be supplied by those people, healthcare providers and Marsh. We may contact healthcare providers for further information, for example to clarify an invoice, discuss an extension to a stay in hospital, or to get copies of medical records. If we need consent to do this, we will get it first.

Personal Information will be used to:

  • provide the services set out under the terms of this plan
  • administer the plan
  • develop customer relationships and services.

Sharing information with the school, any Appointed Guardian and the school's intermediary Marsh

In order to manage the scheme and relationships with the above we may share non-sensitive information with any of the above who may use the information for the purposes and in a manner consistent with this section and/or legal or regulatory purposes. We will also share information about your child's mental or physical health or condition with any Authorised Guardian and if it is in your child's vital interests the school (if not the Authorised Guardian).

Information about your child

When you give us information about other people, we will take this as confirmation that you have their consent to do so.

We will send most correspondence about the plan to the parent/legal guardian. We take both data protection and medical confidentiality very seriously and aim, where possible, to correspond with each individual member over the age of 16 about their claim. This may mean a child under the age of 18 may make a claim without the knowledge of the parent/legal guardian, for example, where the healthcare provider has determined the child is competent to consent to the medical treatment.

Your data and fraudulent claims and other crimes

If we, or others, suspect that fraudulent claims have been made or other crimes have been committed, we are legally required to disclose information to the relevant law enforcement agencies.

We may disclose information to third parties, including other insurers, to prevent or investigate crime. This includes if there is a reasonable suspicion about fraud or improper claims. This may involve adding non-medical information to databases that other insurers and law enforcement agencies and other anti-fraud organisations will be able to access.

Your data and fitness to practise

We are obliged to notify the General Medical Council or other relevant regulatory body if we have reason to believe a healthcare provider's fitness to practise may be impaired. This may mean that we need to disclose information about a treatment episode and your plan.

Marketing preferences

Neither AXA Health nor any other members of the AXA Group of companies will use the personal information provided in this form to contact any person about other products or services. Communication will only be in respect of your child's cover with AXA Health including cover options when your child is leaving the school.

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