Fillable Axa Reimbursement Claim Form printable pdf download

Axa Reimbursement Claim Form

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Reimbursement claim form

This claim form is not an admission of liability.

Please use a separate claim form for each separate visit to the doctor.

Prior approval no:

Date received:

When pre-authorisation required.

NB: In-patient treatment must be pre-authorised

Dear Doctor, we thank you for filling in medical sections B, C and D of this claim form and for signing, dating and stamping it.

Dear Member, we thank you for completing all other sections of this claim form and for signing and dating it. All fields on the front

page are compulsory. We thank you in advance for your cooperation which will enable fast and accurate processing.

A. Administrative

Membership no:

Group/Company name:

dd/mm/yyyy

Patient date of birth:

Gender:

Patient name:

Policy/Group no:

Plan:

Patient phone:

dd/mm/yyyy

For reimbursement only

For hospitalization only

Date of admission:

Date of treatment:

Date of discharge:

B. Medical section

Date the patient first became

Date on which the patient

Symptoms presented

aware of any signs or

first presented to any doctor

symptoms for this condition:

for this condition:

dd/mm/yyyy

Medical condition/diagnosis

Investigation

(Describe necessary investigations requested to define the diagnosis)

C. Treatment advised

Drugs

Dose

Frequency

Duration

Procedure

(Please give details of medical procedures if any)

D. Further treatment planned

Please give details of any further planned treatment

E. Other insurer’ s details

Is the treatment accident related?

Yes

Is it covered under another insurance policy?

Yes

If you have answered 'yes' to either of these questions, please give the name of the Insurance company involved.

Patient’ s declaration

Medical practitioner declaration

I confirm I am the patient, patient’s parent or guardian (if patient under

I declare that I am the patient’s medical practitioner, and that the

16 years of age) and wish to claim and declare that all the particulars

particulars given are to the best of my knowledge true and correct.

given above are to the best of my knowledge true and correct. I hereby

consent to and authorise the medical practitioner involved in the

Name:

Stamp:

patient’s care to discuss treatment details and discharge arrangements

with and to AXA Insurance. I agree that a copy of this consent shall

Signature:

have the validity of the original.

Date:

Signature:

Date:

The member must complete the back of this form

You can download an Acrobat Reader writable version of this form from the website.

Axa Reimbursement Claim Form

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