Escolar Documentos
Profissional Documentos
Cultura Documentos
HeadOffice:SuiteNo.203205,BusinessArcade,P.E.C.H.S.,Block6,
MainShareaFaisal,Karachi,Pakistan
TelNo.(9221)438035761.FaxNo.:(9221)4386451
Part HospitalizationReimbursementClaimForm
B ;
;
TobecompletedbytheTreatingPhysician.
Donotleaveanyblank,unansweredquestions,datesorsignatures,whereverapplicable.
PatientsName:
1. Howlonghaveyoubeenthepatients doctor?
2. Onwhatdatewereyoufirstconsultedfortheinjury,illnessormedical
conditionconcernedorforanyrelatedcondition?
3. Pleasegiveyourdiagnosisoftheinjury/illness/condition?
4. Haveyouanyreasontobelievethatthesameoranyrelatedconditionhas
beendiagnosedortreatedpreviouslybyanyotherdoctororhospital?
5. Hasthepatientconsultedanydoctorfortheabovementionedmedicalcondition? Yes No
IfYes,foreachdoctorandhospitalconsulted,statename,address,andtreatmentprovided.
NameofDoctor/Hospital DateofConsultation ReasonforConsultation Treatment/Results
6. Pleasegivedetailsofthetreatmentgivenor
prescribed?
1. DurationofPregnancy? 1stTrimester nd
2 Trimester
rd
3 Trimester weeks
ForMaternityclaimonly
2. Wouldnormaldeliveryendangerforthelifeofmotherand/orchild(ren)andintra
abdominalsurgerynecessaryforextrauterinepregnancyorcomplications? Yes No
IfYes,pleasegivereasonindetail:
3. Isthereanyperniciousvomitinginpregnancy,toxemiawithconvulsionsor
spontaneousabortion? Yes No
IfYes,pleasegivereasonindetail:
DECLARATION
Iherebycertifythatallanswerstoquestionsappearingonthisformaretrueandcompletetothebestofmyknowledgeandbelief.
DateofStatement:
Signatureoftreatingphysician
NameofPhysician PMDCNo.:
Address: ContactNo.:
Pleaseensurethat:
; UseaNewClaimFormforeachclaimorcourseoftreatment.
; TheIndividualCoveredorhis/herlegalrepresentativesmustcompleteallquestionsofPartAoftheclaim
formandsignit.
; ThetreatingphysicianmustcompleteallquestionsofPartBoftheclaimformandsignit.
; Pleaserecheckandsendfullycompletedclaimformwithallrelevantdocument(s)/ReportstoPakQatar
FamilyTakafulLimited.
; Pleasebeinformedthat;
o IncompleteclaimformCANNOTbeacceptedforprocessingofpayment.
o InsuretoattachORIGINALSofallrelevantdocument(s)/Report.
o InsuretoattachORIGINALbillsandreceiptsofpayment(s).
o PHOTOCOPIESarenotacceptableforprocessingaclaim.
RefNo.GH/CL/2008/00039/1