MediCard Philippines, Inc.

8th Floor, The World Centre Bldg., 330 Sen. Gil Puyat Avenue , Makati City, 1200
Telephone No.: 884-9999 / Fax Nos.: 810-3855; 848-6454
Claims – RE Form
E-mail: inquiry@medicardphils.com / Website: www.medicardphils.com
Rev. 12
14 April 2014

REIMBURSEMENT CLAIM FORM

(Kindly fill out all information with  marks)
Date Filed:

 Patient’s Name: (Given Name , MI, Last Name)  MediCard ID No:

 Principal Member (if patient is a dependent member):  TIN No.

 E-mail Address:  Telephone Number:

 Hospital Name:  Date of medical treatment / confinement:

 Company Name: Total Amount of Claim:

PLEASE CHECK APPROPRIATE BOX FOR PREFERRED MANNER OF RELEASE OF CHECK AND/OR MEMO:
FOR PICK – UP
** IF BY AUTHORIZED REPRESENTATIVE , PLEASE BRING AUTHORIZATION LETTER WITH 1 (ONE) VALID ID OF CLAIMANT AND
REPRESENTATIVE

THRU COURIER / MAIL

MAILING ADDRESS: ___________________________________________________________________________________________
___________________________________________________________________________________________

THRU ACCOUNT OFFICER / BROKER

I attest that the above details are true and correct and I have read and understood the conditions pertaining to the release of any
information regarding my claim.

__________________________________________ _____________________________________
SIGNATURE OF PATIENT OVER PRINTED NAME MediCard AUTHORIZED REPRESENTATIVE
ATTENDING PHYSICIANS REPORT
(in lieu of MEDICAL CERTIFICATE, please have this portion accomplished fully by your attending doctor)
Chief Complaint/s: Laboratory / diagnostic Test/s requested:

Final Diagnosis(es) based on test(s) result(s) (if any): I certify to the best of my knowledge and belief that the information
provided by me in support of the claim are true and correct.

Procedure/s done (if any) ________________________________________________

SIGNATURE OVER PRINTED NAME OF ATTENDING DOCTOR
SPECIALIZATION : _______________________________
License # : _______________________________
Please complete the following BASIC REQUIREMENTS for REIMBURSEMENT
(Failure to do so will invalidate your claim for reimbursement)
** MediCard reserves the right to request for additional documents needed for further evaluation of claim**
Out Patient Reimbursement : For Member Financial Assistance: (Death Claim)
Fully accomplished Reimbursement Claim Form
Cover letter / Incident report (stating the reason for filing of Fully accomplished Reimbursement Claim Form
Reimbursement) Certified True Copy of Death Certificate
Medical Certificate stating chief complaint and final diagnosis Certificate of Employment of the Principal member
Emergency room record MediCard ID or photocopy of any ID of the deceased
Original Official Receipts Duly Notarized Affidavit of Next of Kin / Marriage Contract
Results of laboratory / diagnostic examination Duly Notarized Attending Physician’s Statement Form (in the absence of
Operative Technique (for surgical cases) the APR , we require Morgue or Post Mortem Examination)
Police report (for accidents) Police Report (for accidental death)
Itemized breakdown of charges Copy of Autopsy report (for death of unknown causes)
Subrogation Form (for accidents)

In Patient Reimbursement: FOR SELECTED ACCOUNTS ONLY:

Fully accomplished Reimbursement Claim Form
Cover letter / Incident report (stating the reason for filing of OP Medicine Reimbursement:
Reimbursement)
History of Present Illness Fully accomplished Reimbursement Claim Form
Clinical Abstract Original Official Receipts of medicines
Discharge Summary Doctor’s medicine prescription with diagnosis or with a separate
Original Official Receipt of Hospital bills and/or Prof. fees medical certificate
Statement of account Itemized breakdown of charges
Itemized breakdown of charges or charged slips
Operative Technique (for surgical cases) Optical Wear Reimbursement:
Police Report (for accidents)
Certificate of Live birth and/or Marriage Contract (for maternity Fully accomplished Reimbursement Claim Form
claim) Original Official Receipts
Results of laboratory / diagnostic examinations Prescription for eyeglasses / contact lenses
Subrogation Form (for accidents) Itemized breakdown of charges

GRACE PERIOD FOR FILING OF CLAIMS - 30 days from date of discharge / medical treatment
STANDARD PAYMENT PROCESSING - 15 working days from date of receipt of COMPLETE documents