Medical Insurance Plan - Claim

(Please complete in CAPITAL LETTERS – ONE CLAIM PER CURRENCY)

No. 31120-10007813-20621 V. 2016
TO BE COMPLETED BY THE SUBSCRIBER

Subscriber’s Family name: ARIEL First name: PLATA JIMENEZ

Employee ID: 10007813

Patient’s Family name (if diff.): JESUS DANIEL First name: PLATA MIRANDA

Duty station: COLCU

Were expenses incurred outside the duty station? NO in which country?

Is the illness or injury considered to be service incurred? NO
Have any of the services been or do you expect them to be reimbursed by any other insurance? NO

TO BE COMPLETED BY THE SUBSCRIBER ADMINISTRATOR

CODE - ORIGINAL BILL(S) ATTACHED FOR CURRENCY SUBMITTED AMOUNT CERTIFIED AMOUNT
028 Chemotherapy & Radiation - Outpatient -
029 Day Surgery -
013 Dental Treatment -
003 Doctor’s fees (*1) -
026 Frames -
010 Hearing Aids -
022 Hospitalization – Dr’s fees/Drugs & Medicines/Lab. tests/ X-rays -
001 Hospitalization – Private room (*2) -
002 Hospitalization - Semi-private room (*2) -
009 Immunizations -
006 Laboratory test and X-rays COP-Colombia P 270,000.00
027 Laser Eye Surgery -
007 Medicines -
011 Optical lenses -
014 Orthodontics -
015 Outpatient Psychiatric Care -
017 Voluntary counseling/ testing -
Total amount 270,000.00
*1: Following items are included under Doctor’s fee: Ambulance, Obstetrical services including midwifery, Routine Eye Checkup, Routine Physical Checkup, Well Man Care over 50 years, Well Woman Care

ADDITIONAL INFORMATION FOR AFTER-SERVICE SUBSCRIBERS ONLY

Home address:
Bank name and address:
Bank account number:

I certify that these bills are for services rendered to the above-named person. I hereby authorize the Organization to investigate or seek further information
regarding this claim in accordance with the authorization on the enrollment form.
I understand that incorrect, untrue or falsified information submitted by me, may result not only in the rejection of the claim and/or recovery of overpayments
but also in disciplinary measures under the Staff Regulations and Rules.

Signature of Subscriber: Date: 3-Nov-20

TO BE COMPLETED BY THE ADMINISTRATION

I certify that this claim has been verified in accordance with the rules of MIP and that amounts claimed are considered reasonable.

Name/signature of Certifying Officer: Date:

 MIP CLAIM CONTROL .
SUBSCRIBER: ARIEL PLATA JIMENEZ EMPLOYE ID: 10007813
PATIENT: JESUS DANIEL PLATA MIRANDA DUTY STATION: COLCU
CURRENCY: COP-Colombia Peso CLAIM DATE: 3-Nov-20
SUBMITED AMMOUNT CERTIFIED AMMOUNT TOTAL REIMB
TOTALS $270,000.00 $270,000.00 $216,000.00
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CODE - BILL FOR BILL DATE BILL NUMBER BILL AMOUNT CERTIFIED AMMOUNT TOTAL REIMB. AMMOUNT
11) 006- Laboratory test and X-rays 11/3/2020 1264841 270000 270000 216000
12/30/1899 12/30/1899 0
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ID SFamily_name SFirst_ name Employee_ID Patient_Family Patient_name Duty_station
31120-1000781ARIEL PLATA JIMENEZ 10007813 JESUS DANIEL PLATA MIRANDACOLCU
CalimDate OutsideDS Country service_incurred reimbursed_by_ other_insurance
11/3/2020 NO NO NO
CODE CURRENCY BILL_AMMOUNT BILL_NUMBEBILL_DATE Af_S_Home Af_S_Bank
11) 006- Laboratory tesCOP-Colombi 270,000.00 1/5/5363 11/3/2020
Af_S_Account

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