Scribd Logo
Upload

Welcome to Scribd!

  • Claim Form Pral2

    Uploaded by

    waheedmurad
    322 views1 page
    This document is a claim form for medical reimbursement from an insurance company called Askari Health. It requests information such as the employee and patient name, age, relationship, gender, treatment details including dates, doctor/hospital names, procedures performed, and associated costs. The form has sections for outpatient treatment, specialized investigations, hospitalization/diseases, and requires signatures from the employee, employer, and insurance company.

    Original Description:

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is a claim form for medical reimbursement from an insurance company called Askari Health. It requests information such as the employee and patient name, age, relationship, gender, treatment details including dates, doctor/hospital names, procedures performed, and associated costs. The form has sections for outpatient treatment, specialized investigations, hospitalization/diseases, and requires signatures from the employee, employer, and insurance company.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    322 views1 page

    Claim Form Pral2

    Uploaded by

    waheedmurad
    This document is a claim form for medical reimbursement from an insurance company called Askari Health. It requests information such as the employee and patient name, age, relationship, gender, treatment details including dates, doctor/hospital names, procedures performed, and associated costs. The form has sections for outpatient treatment, specialized investigations, hospitalization/diseases, and requires signatures from the employee, employer, and insurance company.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    o

    g



    CLAIM FORM
    (For Medical Reimbursement Claims)
    askari health
    The health insurance programme
    askari health - Askari I nsurance House, 276-A, Peshawar Road, Rawalpindi. - Ph: 051-5125017-19, Fax: 051-5124918

    Organization Name: __________________________________Employee Name_________________________________
    Designation ______________________________Folio #/Credit Letter #______________ Contact No._____________
    Office Address ________________________________________________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
    SURGICAL

    (Please mention if Normal, C-Section, D&C, Abortion etc.)
    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




    EMPLOYEES SIGNATURE



    EMPLOYERS SIGNATURE





    Date
    (For Office Use Only)
    Sanctioned Amount
    Outstanding Amount_
    Not Payable Amount_

    Sanctioned Authority

    Head Office: 4th Floor, AWT Plaza, The Mall, Rawalpindi. - Ph: 051-9272425-27 - Fax: 051-972424
    Pakistan Revenue Automation Pvt Ltd Abdul Waheed Khan
    Senior Software Engineer
    900769 03335217733
    STP Bldg, 2nd Floor, Service Road North, I-9/3, Islamabad Ali Bahadar Khan
    76 Father Male
    Kulsum International Hospital, Islamabad / Dr. Shazli Manzoor
    04-Jul-2014 2,000/- 900/-
    2,900/-
    07-July-2014

    You might also like