Level Health
Level Health hospital claim form
Where Level Health pays the hospital directly, this form carries the admission; the consultant completes the clinical and procedure sections and signs with a Level Health doctor code.
The form itself is Level Health’s: the official form, on Level Health’s site (link checked 24 October 2026). Below is what each person fills in, where it goes, and the document we provide beside it.
What it asks for
The patientThe patient completes
- Accident or injury details and solicitor, where applicable
- Data protection statement
- Declaration and direct payment authorisation
The consultantThe consultant completes
- Reason for admission (admitting diagnosis)
- Procedure, procedure codes and date
- Clinical indication code and ICD code
- Type of anaesthesia
- Medical investigations: laboratory and radiology
- High-cost drugs administered
- Discharge status
- Consultant name, Level Health doctor code, signature and date
Where it goes
- When Level Health has a direct payment arrangement with a facility, the form is completed in full so the claim settles directly between the facility and Level Health.
- The patient authorises direct payment to the doctors, consultants or hospital for the services listed on the form.
Using it well
- The form asks for up to three procedure codes and the ICD code; have them before the consultant signs.
- The Level Health doctor code is issued on registration; keep it with the practice's insurer details.
Insurer claim submission is not in Ask Brigid’s launch release.
Open it in the sample practice
The sample practice is the real Ask Brigid on invented patients, open without a sign-up. This document joins its Library with the next sample-practice update; the Library already holds the practice’s templates.
Sources
- Level Health hospital claim form, read 24 October 2026
Checked against the sources above on 24 October 2026. Issuers change their forms; check the official page before you rely on a detail here.
Questions
What does the consultant complete on the Level Health hospital claim form?
The admitting diagnosis, the procedure and its codes with the date, the clinical indication and ICD codes, the anaesthesia type, the investigations, any high-cost drugs, the discharge status, and the sign-off with the Level Health doctor code.
Who pays the hospital?
Level Health, directly, where it has a direct payment arrangement with the facility and the form is completed in full.
Does Ask Brigid submit the claim to Level Health?
No. Insurer claim submission is not in the launch release. The companion worksheet gathers the consultant's section so it can be copied onto the form.
In Ask Brigid this paperwork sits beside the diary and the record: Invoices and card payments in Ask Brigid.