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  • Penta Care

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    Mo0nStaR
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    REIMBURSEMENT CLAIMS FORM To be filled by the patient / Physician CHIEF COMPLAINT / SYMPTOMS: PATIENT NAME: Member Insurance ID: Patient Tel: date of present onset: chronic acute Congenital Condition. I declare that I am the patient's medical practitioner, and that the particulars given are the best of my knowledge true and correct. Attach all the original invoices, investigation results and medical report along with this form for claims reimbursement subject to policy terms and

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    REIMBURSEMENT CLAIMS FORM To be filled by the patient / Physician CHIEF COMPLAINT / SYMPTOMS: PATIENT NAME: Member Insurance ID: Patient Tel: date of present onset: chronic acute Congenital Condition. I declare that I am the patient's medical practitioner, and that the particulars given are the best of my knowledge true and correct. Attach all the original invoices, investigation results and medical report along with this form for claims reimbursement subject to policy terms and

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    39 views1 page

    Penta Care

    Uploaded by

    Mo0nStaR
    REIMBURSEMENT CLAIMS FORM To be filled by the patient / Physician CHIEF COMPLAINT / SYMPTOMS: PATIENT NAME: Member Insurance ID: Patient Tel: date of present onset: chronic acute Congenital Condition. I declare that I am the patient's medical practitioner, and that the particulars given are the best of my knowledge true and correct. Attach all the original invoices, investigation results and medical report along with this form for claims reimbursement subject to policy terms and

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    REIMBURSEMENT CLAIMS FORM

    To be filled by the patient / Physician PROVIDER NAME: Date of Treatment: DOB : Patient Address: To be filled by the Physician CHIEF COMPLAINT / SYMPTOMS: PATIENT NAME: Member Insurance ID: Patient Tel:

    Date of present onset:

    Diagnosis: Diagnosis Code:

    Chronic

    Acute

    Congenital Condition

    Clinical Findings : Physical Findings:

    B.P

    Temp:

    HR:

    RR:

    PR:

    Details of any investigations Done :

    Details of the Treatment Done :

    I declare that I am the patient's medical practitioner, and that the particulars given are to the best of my knowledge true and correct. Name of the Physician: Signature Date STAMP I hereby authorize any Healthcare provider, Insurer to release any information regarding my medical condition & history to Pentacare for the purpose of determining insurance benefits. Patients Name & Signature: Date:

    * Attach all the original invoices, investigation results and medical report, Discharge summary (if Inpatient) along with this form for claims reimbursement subject to policy terms & conditions Pentacare Contact Information: TEL: 04-2946443 FAX: 04 - 2946448

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