IN-PATIENT MEDICAL EXPENSES CLAIM FORM

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IN-PATIENT MEDICAL EXPENSES

CLAIM FORM

NOTE:

This form is to be supported with paid receipts, prescriptions and discharge summary* of the hospital in original.


POLICY PARTICULARS:

Policy No.:

Name of Company:

Name of Employee:               Emp ID# _____________________

Name of Patient: ____________________________

Age of Person hospitalized: __       Relationship with Employee: ____________________________

Wellness Card Number: _________________________________________________________________


DETAILS OF ILLNESS:

Date of illness first noticed:

Date of recovery:

Diagnosis:

Has the claimant suffered from this illness before? YES/NO

If yes, please give date(s) and details:


DETAILS OF HOSPITAL:

Name of Hospital attended:                                    

Name of medical practitioner consulted:                  

Period of confinement: From: To:                             

Were any drugs prescribed: Yes/No                    

If yes, please list the drugs prescribed and administered:                  

                 


OTHER INSURANCE:

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*


Name of expenses

Amount





                Total



*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:


  1. 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.


Date: Signature:


  1. 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.



Date: Signature:


(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.



Date: Signature:


NOTE:

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.



CHECK LIST FOR CIENT PURPOSE: Requirement for Reimbursement

  • Inpatient Claim Form (filled and stamped by the employer and treating Physician)

  • Copy of Wellness card 

  • Proper itemized hospital original bill with following details

  • Room Board charges

  • Lab charges with reports

  • Pharmacy details with cost.(Receipts should have date, printed name & address of pharmacy or stamp of issuer)

  • Surgeon, anesthesia and O.T charges (applicable in surgical Procedures)

  • Labor room charges (in maternity cases)

  • Original Discharge card/Summary

  • Detailed breakup of Ancillaries & supplies with cost.

  • Birth certificate in case of Delivery


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