Form Frm-Cf - Claim Form Page 3
ADVERTISEMENT
1
2
3
4Sections 5 and 6 are to be completed by the treating doctor unless detailed in the supporting documentation (e.g. receipts or invoices).
5 Medical provider’s details
Name of doctor/specialist
Qualifications/credentials
Name of hospital/clinic
Address
Telephone number
(incl. country code and area code)
Fax number
(incl. country code and area code)
Email
Applicable to physiotherapy/psychotherapy claims only. Please provide full referral details:
Name of referring physician
Telephone number
(incl. country code and area code)
Date of referral
(DD/MM/YY)
6 Medical details
Indicate type of treatment received
Elective
Emergency
Indicate type of condition
Acute
Chronic
Acute episode of chronic
Please provide full details of the symptoms/medical condition requiring treatment, including ICD9/10 code/DSM-IV
On what date did the patient first present these symptoms to you?
(DD/MM/YY)
On what date would the first onset of symptoms have been apparent to the patient?
(DD/MM/YY)
Has the patient suffered from this condition previously?
Yes
No
If Yes, when?
(DD/MM/YY)
Are you aware of any treatment given for this or any related illness in the past?
Yes
No
If Yes, please provide details
Is it likely to re-occur?
Yes
No
Does it need rehabilitation?
Yes
No
Is it permanent?
Yes
No
Does it need long term monitoring, consultations, check ups, examinations or tests?
Yes
No
Applicable to cases of pregnancy only:
Estimated date of delivery
Is birth of a single baby expected?
Yes
No
(DD/MM/YY)
If you answered No to the question above and twins/multiple babies are expected, is the pregnancy a result of medically assisted reproduction other than artificial insemination?
Yes
No
If Yes, please provide further details
Applicable to dental treatment claims only:
Was the patient suffering from dental pain at the time he/she visited you for treatment? Yes
No
Please sign and authenticate with an official stamp.
Official stamp of medical provider
Doctor’s signature
Date
(DD/MM/YY)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business