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  • Opd Claim Form

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    khan gee
    61 views2 pages
    This document is a claim form for medical expenses from an insurance company. It contains sections for the employee, attending physician, and policy holder to fill out. The employee section includes information about the patient, relationship to employee, nature of visit, doctor and treatment details, and expenses. The physician section requires the patient's name, diagnosis, treatment details, signatures and credentials. The policy holder section needs their signature to verify the claim. Required attachments include original receipts for charges, prescriptions, lab tests, and examinations.

    Original Description:

    JUBILEE Medical claim form

    Original Title

    OPD CLAIM FORM

    Copyright

    © © All Rights Reserved

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    This document is a claim form for medical expenses from an insurance company. It contains sections for the employee, attending physician, and policy holder to fill out. The employee section includes information about the patient, relationship to employee, nature of visit, doctor and treatment details, and expenses. The physician section requires the patient's name, diagnosis, treatment details, signatures and credentials. The policy holder section needs their signature to verify the claim. Required attachments include original receipts for charges, prescriptions, lab tests, and examinations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    61 views2 pages

    Opd Claim Form

    Uploaded by

    khan gee
    This document is a claim form for medical expenses from an insurance company. It contains sections for the employee, attending physician, and policy holder to fill out. The employee section includes information about the patient, relationship to employee, nature of visit, doctor and treatment details, and expenses. The physician section requires the patient's name, diagnosis, treatment details, signatures and credentials. The policy holder section needs their signature to verify the claim. Required attachments include original receipts for charges, prescriptions, lab tests, and examinations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 2

    Don't leave any blank, unanswered question medical reports, dates and / or signatures, where ever applicable

    PART A - EMPLOYEE'S SECTION

    Company's Name

    Policy No ______________ 1 Certificate No, 1 _

    Employee's Nome

    Patient's Name

    Relationship with Employee D Sell D Wile D Son D Daughter D Age Sex D fv\ole D Female
    Nal\Jre of Visit: D Sickness

    D Accident

    Doctor's Nome

    ConsultatIon E)(pen~es Medical Expenses

    Per Visit No. of Toto! Expenses No. of Receipts Amount


    Type 01 Visit
    Rate Visit Amount Title Attached Claimed

    Clinic Visits Medicine

    Home Visits Laboratory

    Specialist Visits X-Rays

    Other Tests Other Tests

    Sub Total Rs. Total Amount Rs,

    B/F Sub Total Rs

    Toiol Claimed Rs.

    Amount claimed (Rupees Onlyl

    I hereby certify that all answers and all documents submitted with this Claim Form ore complete and true. I , the above claimant, hereby
    authorize any doctor, hospital, clinic or any other person who has my record or information about me and lor any 01 my family
    members to provide Jubilee Health Insurance with the complete in/ormation, including copies of their records with reference to any
    sickness Of occident or ony treotment, Any photocopy of the authorization shall be token as the original copy.

    Employee', [Cloimo,'1 Sig,a'cce I, _ Da'e 1 _

    CSD-T
    Don't leave any blanks, unanswered question medical reports, dates and / or signatures, where ever applicable

    PART B - AITENDING PHYSICIAN'S SECTION

    Patient's Name ~ _

    Diagnosis (Block lettersl

    Symptoms first appeared on I~ I Date of first consultation

    Is consultation directly related to pregnancy / childbirth? DYe, D No

    Dotes of Treatment / consultation Detail of treatment / consultation Visits

    Details of Treatment (other than prescription):

    Doctor's Signature & Official Stamp Date I~ _

    Physician's tv\ailing Address & Telephone No,


    ------------------------------
    PMDC No.I 1 Speciality 1 1 Fees / Charges 1 _

    PART C - POLICY HOLDER'S VERIFICATION SECTION

    A",ho,ized pe"oo', 'igoa'",e 1 _ Date 1 _

    End.:
    • Official receipt (original) showing the attending physician's detailed charges along with his stamp and signature .

    • Itemized pharmacy bill shownig the date of purchase, nome of patient, quantity and name of drugs along with the physician's
    prescription .

    • Official receipt (s) showing charges for each of the lab Test, X-rays films, and other examinations done and supported by the
    respective physician's request to undergo examinations and copies of the results of examinations undertaken.

    Jubilee Health In~urance


    Corporate Office, 2nd Floor, PNSC Building, lalozor, M.T. Khan Rood, Karachi. 74000, Pakistan
    Pha,. 1021135657885 Fa" 1021135611349, 35644315
    Email: info@jubileeheahh.com
    CSD-T

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