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  • Manulife Form - Asuransi Rumah Sakit

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    Ronal Gorba Timothy
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    Informasi mengenai asuransi Manulife

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    Informasi mengenai asuransi Manulife

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    61 views2 pages

    Manulife Form - Asuransi Rumah Sakit

    Uploaded by

    Ronal Gorba Timothy
    Informasi mengenai asuransi Manulife

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 2
    IM Manulife Financial Aran ia Manners Grete uments ep ‘Senor Sate are Seu Tone 3.17 ed aden asks 2990 utah 25587897 oman Oi ac 6h 5892009 FORMULIR KLAIM PERAWATAN RUMAH SAKIT DAN PEMBEDAHAN ASURANS! KUMPULAN GROUP HOSPITALIZATION AND SURGERY INSURANCE CLAIM FORM PETUNJUK PENGAJUAN KLAIM / GUIDELINE OF CLAIM SUBMISSION "For are is dengan enka, Bear dn ln lac haya dapat diroses ile seus dokuren teh lenokap./ Ns For sod be les cone ‘Sipe andy Can wont probe posed alappueg cements same pee = 2. Kain dapat proses hanyabia sem dolenen norma, asa engan penclanny takep rep cba bat dans pemetisaan pemonn ih iampirion Sengeniongop.' li conbe cured fal cers siniich ain orm ong ecept wh ede a neoRere ces Selim prscicn aw ser smprig ose eatin a ect areched Rema hh BAGIAN A. KETERANGAN KEPESERTAAN POLIS / INFORMATION OF PARTICIPANT (dis oleh pesera /pinakyang mengajukan ksim led by claimant) Pemegang Pals ray ede = “ - omer Polis Disb pein eda hlsarg haryanen Poynter fledndratent emotes tondymene? Name Karyonan Namo Pasion Eimplyecs ome Potersnome - Tanggalshe = HiubunganKelusrga: [) ti) suum] anak Bove arch ~~ ceecentnneeneneceenn RMCWOPD Oe 0 hie Ol oa mor Sertiat + Tanggaahir = i Oe ane Daeatonm — “ Nomor Seriat Certo aber Apalattlsin ni juga dijukan kepada Astransiladivid PT AJ Manulife Indonesia atau perusahaen ast [ibis claim ato subrated fo lndiviaual nuronce oF PAI Menublegonesi oothernsurace company? Yes No. Narva Perusahaan Asuransi ‘Name otisuranee Company, ‘Alamat lengkap /Flladdiess Nomor Polis / Policy number ‘ie pengejuon Maik eta ke pembayeran Klee okan ilkukansesel dts nomorrehenng yong anda dberikan ch Pemepeng Pols. la ode ‘eruoahan,mehon dberhan surat pernyetaan yang ctandatangateeh Pemegang Pei. /hclam seppoved te cin payment ne tonstaedtothe acount ‘arabe hates bon sven bythe Poet ee ny chores pa reid the saree eter gn y Po har “Sapemeeyaatantahon (ap wah wembaca merge era renee dn once nnd eo ca py rn tan fa ban ns pan hug brow ima o reas sm ee ae ey Sree ceca ac ny po oan a ner pata a tn ob ai cao Ditandatangani di signin. Tanggal/ Dated. Dibuatoleh ade by (fanda tangsn, name jeles & stempel Perusahaan) ‘Tanda tangan, nama elas karyawan & keluarga karyawan) (signature, name, stamp of company) (signature, name of employee ‘employee's farmly) Jabatan Postion: BAGIAN B, KETERANGAN DOKTER / MEDICAL RESUME (disoch dokteryang merawat/ Filed i by doctoria-charge) Nama pasion Tanggal perawatan Patents name Datear hesptalzation Jka pasln idk drawat, pata pasion mendapatkan perawatan sa pada sant masul RS/Sprptonn when erteing te Hosts airubngtnt Gout OmnreeWUGDl# ten rorhorsraea aa | APM patent Rove Emergency Room (eR rectmen’? varies Tako Tanggalgeaa pert kali dhetahut EL 6a a Baredtsmnponisar tna aanowecged tka, mask USD, puta: ves admited to & tne Pasion portama kali berobat untuk penyakittersebut Fist medical trentrenerforedtothefines Keluar U6D, pukul Discharged omen, time mom] Tanggal/ Bote ‘Tindakan yang dilskukan / Actions then: Nama Dokter / Doctors Name #.o.c---mnnnnn : ‘Alamat lenghap / Full dress Penyakitiniterjalarenartergolong: C) Kecsakaan eccden © rehamitan/ Pregnancy © Kawaan/Paychiatc Imvbies defo cotegonceder Instines idee O kelsinam bawaan/ Congenital O Laitain/ Others ( emneriksnan fis jens pemeriksaan penunjang yang dilakukan/ Piysica examination and detail of aiagnostc examination: Diagnose Diagncse : ‘Obat-obat yang diberkan (Treatment Operas Surgery : eS ka diawat oleh lebih dar 1 (satu) dokter sebutkan nama dokter dan spesialisasinya thepatient wos token care by more than 1 one} doctor, pease state the nme and the specalation ofthe doctor ‘Apakah pasion pemah konsultas/dirawatsabelummya? — QYa/Yes —QTidak/ No _—Bla“YA Jawabportanyaana, bcd ‘Have thepotint over Been consulted hospitalized before? W°105'pleaseanswere bcd 2.Tanggal/ Date ‘Diagnose Disgrose ‘Nama Dokter / Name of Doctor

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