HOSPITAL CASH CLAIM FORM

IMPORTANT: EASTWEST AGEAS LIFE INSURANCE CORPORATION reserves the right to require
further information should it be deemed necessary.
TO BE ACCOMPLISHED BY THE INSURED:
Full Name of Insured: Date of Birth: Marital Status:

Complete Address: Occupation: Contact Number/s:

Policy Number: Effective Date:

Nature of Claim (Please Check): Illness Injury Others: _________________________________

Please describe nature of claim:

When did symptoms first appear or the injury When did you first consulted a medical doctor for this
happened? condition?

I HEREBY CERTIFY that the foregoing answers are true and correct to the best of my knowledge and HEREBY
AUTHORIZE all doctors and / or other persons who attended / treated me and all hospitals and / or other institutions to
furnish full information and complete copies of all medical records regarding this claim.
I authorize any physician, medical practitioner, clinic, hospital, other health facility, insurance company, government offices
or employer to release all medical and non-medical information about me in its possession to EASTWEST AGEAS
LIFE INSURANCE CORPORATION or its authorized representatives.
A photographic copy of this authorization is valid as the original.
Complete Name and Signature of Insured / Claimant: Date and Place of Signing:

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TO BE ACCOMPLISHED BY THE ATTENDING PHYSICIAN
Full name of Patient: Age:

Type of Availment: Elective Emergency Date of Availment or Admission:

Date Discharged:

Brief clinical history and pertinent physical findings:

When did symptoms first appear or the injury When did the patient first consulted you for this
happened? condition?

Had the patient suffered from the same or similar Final Diagnosis:
condition? If yes, please provide details.

Please provide details of any surgical operations performed or contemplated to be performed to the patient:
Date of Operation Name of Physician and Hospital Type of Operation

Names and addresses of other physicians that treated the patient for this illness / injury.
Name of Physician / Hospital / Address Contact Numbers Dates Attended
Institution

I hereby certify that the answers and information given above are full, complete and true.
I further authorize the Medical Director or any of his/her authorized representatives to furnish EAST WEST AGEAS
LIFE INSURANCE CORPORATION or its authorize representatives all medical records of the patient.
A photographic copy of this authorization is valid as the original.
Complete Name and Signature of Attending Physician: Date Signed:

Specialization: License Number: Contact Number/s

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