IN-PATIENT MEDICAL EXPENSES
This form is to be supported with paid receipts, prescriptions and discharge summary* of the hospital in original.
Is the patient entitled to payment under any other insurance in respect of this ailment? Yes/No
If yes, please give details:
AMOUNT OF CLAIM:
Please list in the column below all expenses claimed and attach original (not photocopies) of all relevant paid receipt supported by relevant prescriptions and discharge summary*
*Discharge summary means a concise description of the patient’s hospitalization entered into the medical record, including the reasons for admission, findings of laboratory testing and other diagnostic procedures, the discharge diagnostic provided by the attending physician upon the patient’s discharge from the hospital and instructions for the patient.
DECLARATION BY THE INSURED PERSON & ASSURED:
To be signed by the Insured Person
I declare that to the best of my knowledge and belief the statements contained herein are true and that all relevant information has been disclosed.
To be signed by an official of the Assured
I confirm that at the date of claims the member of whose behalf this claim is made was an eligible employee in terms of the policy.
(c) Declaration by the attending Doctor
I confirm having treated Mr/Mrs/Miss:
between the dates and
and that the details shown on this form are consistent with my own knowledge of the patient.
For speedy settlement of the claim, we request you to please fill in each and every column with as much details as possible. Please do not leave any column blank.
Thanks for reading: IN-PATIENT MEDICAL EXPENSES CLAIM FORM, Sorry, my English is bad:)