Medical Claim Reimbursement Form - Wehbe Insurance Services Llc Page 2
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2Medical Claim Reimbursement Form
ATTENDING PHySICIAN SECTION (*Mandatory Fields)
Patient’s Full Name
Date of Birth
D
D M M
Y
Y
Y
Y
Chief Complains*
Diagnosis*
How long has the patient been suffering from this sickness?*
Please specify the date symptoms first appeared.
If treated by other medical provider please specify the name and treatment details
If the claim is resulting from pregnancy / childbirth, please provide the LMP*
Details of the treatment (other than Prescription)
If further treatment or operative procedure anticipated, please provide the details
Physician’s Name, Address and Tel. No.
Physician’s Signature and Stamp
American Life Insurance Company is a MetLife, Inc. Company
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