Check List for Mediclaim Process

(Please tick YES / NO )

Duly filled Mediclaim Form YES NO

Duly filled Medical Certificate from YES NO

Discharge Summary YES NO

Hospital Final Bill & Cash receipt for payment YES NO

All Lab report with Prescription YES NO

All Medical bills with prescription YES NO

Member Information

Employee Code

Deputee ID

Deputee Name

Client Name

DOJ

HRD/KAM Name

Location ( Ma Foi Centre)

Date : Signature of the HRD/KAM