Unit 1410 Prestige Tower Condominium, F. Ortigas Jr. Ave.

, Ortigas Center, Pasig City

Tel Nos (+632) 8477-4758 to 60 Website: www.hppi.co.ph Email: info@hppi.com.ph
CLAIM FORM

Date: _______________________
Member’s Name: _______________________________ HPPI ID No.: _____________________ Effective Dates: _______________________________
Address: ___________________________________________________________________________________________________________________
Company Name: ___________________________________Member’s Telephone No.:____________________ Mobile No.: ______________________
Hospital/Clinic: ________________________________________ Attending Physician/s: ___________________________________________________
Availment/Confinement Date/s: _____________________ Complete Diagnosis___________________________________________________________
*For a faster reimbursement, check payment may be deposited directly to your bank account (indicate details below) –
Bank:________________________________________ Name of Account Holder: _______________________________________________
Type of Account: ______________________________ Bank Account No. _____________________________________________________
Address of Bank Branch: ___________________________________________________________ E-mail: __________________________________
(Note: Claimant should be the owner of the bank account above. Bank account must be accepting check deposit.)

Type of Claim:
____Out-Patient _____Maternity Assistance Accident: Motor Vehicle / Work (encircle)
____Confinement _____ Disability Assistance Family Medicine Assistance
____Emergency Room Death Assistance Others (please state):_____________________________

Checklist
Basic: Family Medicine Assistance:
___ Filled up HPPI Claim Form Original official receipts
___ Original Official Receipt Accidents (Personal / Motor Vehicular)
___ Original Statement of Account ___ Original Official Receipt, Statement of Account,
___ Original Itemized Bill or Charge Slips Itemized Bill, and Medical Certificate / Abstract
___ Medical Certificate or Written Doctor’s Diagnosis ___ Police Report
___Copy of Driver’s License and Vehicle Registration (for MVA)
Maternity Assistance: Death Assistance:
___ Certified True Copy of Birth Certificate* ____ Certified True Copy of Death Certificate
___ Original Receipts ____ HPPI Membership ID of the Deceased
___ Original Statement of Account ____ Valid ID of Claimant Next of Kin
___ Original Itemized Bill / Charge Slips ____ Duly Notarized Affidavit of Next of Kin
___ Medical Certificate ____ Attending Physician’s Statement Form / Medical Certificate
____ Original Police Investigation Report (if due to accident)
____ Photocopy of Marriage Certificate / Birth Certificate if claimant
Is a spouse or parent/child respectively
NATURE / CIRCUMTANCES OF THE CLAIM:
(Please give details/nature/reason for the claim. You may use an additional sheet of paper if necessary.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________

I hereby authorize HPPI, its representative/s to access, secure, handle and process my personal information and medical records necessary for the reimbursement and processing of my
claim, recording/reporting of medical utilization, among other official purposes in relation to my healthcare program under HPPI and in keeping with the Data Privacy Act of 2012. I
understand that I am entitled to access and to request correction of the personal information that I will be submitting to HPPI, and that I may also withhold my consent for my personal
information to be used in the future by means of a formal request and correspondence duly received by HPPI. I also understand that I may report concerns on Data Privacy to the Data
Privacy Officer of HPPI - Bill Jose M. Obag / telephone number (02) 8477-4758 and via e-mail dpo@hppi.com.ph. This undertaking is being made by the undersigned with my full
knowledge and consent and without any coercion.

______________________________________________
(Original Signature of Member above Printed Name)
(Note: In order to avoid forfeiture of your claim, please submit / send the properly filled-up Claim Form along with Complete Supporting Documents within the prescribed
number of days to HPPI. For inquiries or assistance please call the HPPI 24/7 Hotlines: 0922-8089897, 0922-8090010, 0917-8269693 and (02) 8984-5065).

Ver. 4 / 11/18/2021