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  • Asian Life Out Patient

    Enviado por

    dinson123
    23 visualizações1 página
    The document is an out-patient claim form for an insurance policyholder. It requests information such as the employee and patient names, date of consultation, diagnosis, physician recommendations and signature. It instructs to attach the original doctor's prescription and receipts when submitting claims for reimbursement.

    Descrição original:

    Asian Life Hospital

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    © © All Rights Reserved

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    The document is an out-patient claim form for an insurance policyholder. It requests information such as the employee and patient names, date of consultation, diagnosis, physician recommendations and signature. It instructs to attach the original doctor's prescription and receipts when submitting claims for reimbursement.

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    23 visualizações1 página

    Asian Life Out Patient

    Enviado por

    dinson123
    The document is an out-patient claim form for an insurance policyholder. It requests information such as the employee and patient names, date of consultation, diagnosis, physician recommendations and signature. It instructs to attach the original doctor's prescription and receipts when submitting claims for reimbursement.

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 1

    G/F to 3/F Morning Star Center, 347 Sen Gil J. Puyat Ave.

    , 1200 Makati City, Philippines


    Tel (632) 890-1758 Fax: (632) 895-8519; 895-8524 *website: www.asianlife.com.ph
    NON VAT REG TIN: 000-169-096-00

    OUT-PATIENT CLAIM FORM


    Name of Employee:
    Policyholder:

    To be accomplished by attending Physician:


    Name of Patient: Date of Consultation:
    Sex: Age:
    Complaints :
    Recommendation - Laboratory Examination:
    - Prescribed Medicines:
    Final Diagnosis:

    ATTENDING PHYSICIANS SIGNATURE OFFICE ADDRESS & TELEPHONE NO.


    OVER PRINTED NAME LICENSE NO.

    EMPLOYEES SIGNATURE EMPLOYERS SIGNATURE (HRD)

    PLEASE MAKE CHECK PAYABLE TO (To be filled up by the Insurance Broker or Company HRD Head)

    Note: Please attach this form to the ORIGINAL Doctors Prescription and Official Receipts

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