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CLAIM FORM The health insurance programme

ask (For Medical Reimbursement Claims)

askari health - Askari Insurance House, 32-A, Haider Road, Saddar, Rawalpindi. - Ph: 051-5700170-1, 5700173-4 - Fax: 051-5700172

Organization Name__________________________________________________________________________________
Employee Name_________________________________________________Folio No. / Credit Letter No.____________
Designation________________________________________Patient Name_____________________________________
Patient Age_________________Relation with Employee______________________________Sex(M / F)_____________

OUT DOOR TREATMENT (OPD)

(Please attach itemized Bills, Original Prescriptions, Lab. Test Reports and Original Receipts)

Name of Clinic / Hospital and Doctor____________________________________________________________________

Date of Visit__________________Consultation Fee (Rs.)________________Cost of Medicine (Rs.)_________________

Cost of Investigation / Lab. Test (Rs.)_______________________________Total Cost(Rs.)________________________

SPECIALIZED INVESTIGATION

Name of Hospital / Institution___________________________________________________________________________

Referring Specialist / Consultant________________________________________________________________________
Cost of Investigation / Procedure (Rs.)___________________________________________________________________
(Please tick which ever is applicable)
MRI (Magnetic Resonance Imaging) ERCP (Endoscopic Retrograde Cholangio-Pancreatography)

CAT SCAN (Computerized Axial Tomography) ANGIOGRAPHY NUCLEAR SCAN

Date of Intimation________________________________Date of Approval______________________________________

HOSPITALIZATION / DREAD DISEASE / MATERNITY

Name of Hospital / Institution__________________________________________________________________________
Name of Treating Physician / Surgeon___________________________________________________________________
Date of Admission_________________________________Date of Discharge___________________________________
(Please tick which ever is applicable)
HOSPITALIZATION DREAD DISEASE MATERNITY Ante-Natal Natal Post-Natal
MEDICAL (Please mention if Normal, C-Section, D&C, Abortion etc.)
SURGICAL
Diagnosis / Procedure______________________________________________________________________
Room Charges_____________O.T / Labor Room Charges_____________Cost of Surgeon______________
Cost of Anesthetist __________Investigation & Lab. Charges__________Cost of Medicines_____________
Consultant / M.O Visit Charges _____________Other_____________Total Cost (Rs.)____________________

Name, Signature & Seal / Stamp

of Doctor / Hospital / Institution

(For Office Use Only)

_______________________ Sanctioned Amount________________________
EMPLOYEES SIGNATURE
Outstanding Amount_______________________
Not Payable Amount_______________________
Date_________________
_______________________
EMPLOYERS SIGNATURE Sanctioned Authority_______________________

Head Office: 4th Floor, AWT Plaza, The Mall, Rawalpindi. - Ph: 051-9272425-27 - Fax: 051-9292424