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    12 views2 pages

    1 Digabungkan

    Uploaded by

    yuli

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    © All Rights Reserved
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    ‘etunjuk Pengajuan Kiaim / Claim Submission Guidelines Formulr in harus dil dengan lengkap, benar, elas, dan dtandatangan! oleh peserta atau orang tua jka pasion adalah anak-anak This form should be ited with complete, correct, clear information and signed by insured person or parents the insured person's minor Formulrin beriaku untuk 1 (Satu) oteng pasion ‘This forms vali fr 1 one) pationt Kiaim bary dapat dite! dan diproses lebih lanjut hanya bila semua dokumen pendukung pengajuan klaim yang sesualtelan dis, clengkapi dan Glamptran. Coke pending pengehan Kan tre metpul: Sut Jaren (epeblenanggunak amar, Forui Kian, Kutar aa ‘esata perncannya yal: rama pasion, angel perewatan, blaya perewala, copy resep chat cbatan hes pemeriksaanpertnjang agreed (Laboratorium, Radiologi Histopatolog. i) aim can only bo processed subject o al rested supporting documents nave been filed, completed and attached. The supporting documents shal Include: Guarantee Later (lor Guaranteed Hospitalization), Ciaim Form, Orginal receipt bearing the patient's name, treatment date, charged amount, tailed report of medical prescription, dlagnostc report (Laboratory report, Radiology report, Histopathology report tc). ‘ilsloleh pesorta asurans| atau orangtua pasion bila paslen adalah anak-anak ‘led by the insured person or his/her parents ifthe patient Is minor ATA PEMEGANG POLIS / KARYAWAN DATA PASIEN 2olicy Holder / Employee information Patient's information cre aaa OST rar EIT sem __| Pamrname [Enel fusft ta z comnts =e Oey Ne. 2 00301 6 56 O 6030 YE ESEO MombershipNe. | 2 C, ‘Bre Karyawan /Teranggung Tanggel Lahie 7 a mpoyoo's/ Insured's name Lewy Pus Brfo. Date of Birth 1a lol IGS omer Poser SS eee “rat No Top cs ites Teophone No. Cait Ht" — anak Crtaron vant / Husband SOM sends” Ownsot shed See p009 jvebola Male Lb M020 Cin orgs Koger ann! brie Pelayanan Modis / Medea! Service Type “Rawat inap Inpatient (ORawat Jalan / Oupavent Kehaman Meehirtan / Matemty Rawat Gig\/ Dental C:Kecamata Optica! Ta ada pole sera an yang renanagung perauatan i, ohon WfomasKan nama pavusaheanasuano) alana, dan nomer flepon ‘Stor rearence poles coven ins Heaven, pease sso name of te nsurance camary, aes, and ialephone number otal Jumtah Kiaim / Total Claim amount: ¢ 229.000 aya menyatakan bahwa saya telah membace, mengert, an menjawab pertanysan nae anh seit ee ee sma ke feclere that have read, understood and answered al the questions above completely and correct. | hereby authorized any physician, cini, ‘spiel public health contres, ineurance company, logal institution, personal or other organizations that has any records or information on the tanh of the Insured person to inform PT Equly Life Indonesia or its authorized party, ary explanation about my health condition. A photographic ‘py ofthis siatoment should be valid and legal es the original. ‘and Date; bogor 2° 73 77 sto Tepet dan Tage Tanda Tkeloarga Karyawan 7 pemegang pole Rertanggung « Signature tl name of employee / open / poy holder / inured parsan 1 ty le dows ie Sie DA ae Sco 4 09 ne: 29 fe 2 BOT. meet) Ue He » certify that! personally have examined the below patient's sickness andor injury. ‘apsion/ Potente Name Endy Vusgito _____NomorRetam Modia/ Modo! Record No (000) 20 _ ‘shan dan Gejala utama/ Primary symptor:sMid sins: Badu - ‘ Shan dan Goji Tabehen / Ofer symptoms andre Domnem Of) , Saul befola Cr), bval w) ‘ak vapan Keluhan dan goals ‘irasakan oleh pasion ? Since when he symptoms and signs suffored by the patient ? Shacr _Seoelm _masu Us ‘aa diaitkan Reval inap/ indication for Hosphalzaon . Jan Glakikan Rawal nap / Purpose of Hoaplalzaton bsecvasi/ Observation (1Diagnostk 7 Diegnostc CTetept Therapeutic nerksaan Fisk / Physicial examination: 66S SCF TO" Were, ERT Pte eae sehmphiten AMA S/n tle btasne ~ fom pd Lahap oo TAAL 3 tn german ty Jambing Luby ry ed gee saw ® Ltd] a ERT oetef Ono: Toute EY ae Spl Therpy: Uo Praca Oe \GTOM, (uj) Ondanuenben \ * ply makewine tm ‘Ka. cotammya pasion pemah mendapatian perawslan uniukKeedsan/ponyakit yang sama 7 Mofonjlaskan 9 the patient ever been treated for the same sickness / injury ? Please explain. Pda errno “Treroparan pasion Rojuken_mohoninformasican nama, slant, dan nomorllopon door danlatay instal Kesshelan yang meruuk ‘fared pater ploose atte the nano, adores ad telephone number othe refering phyeisan andir hoa ineuion ‘Javan atau Pembedanen yang Glakuxen Slama porewatan/ Procedures or Surgical performed during restment = {Sen inoviih jos trl@XAP Blau pomnbecahan wrseh=" Ur atas / Reason to sioose the abcve Procsowes O° SUDO ‘Kah penyakt/ Kondis| di alas disebabkan alau berhubungan dengan = 4 above sickness / condition caused by or related to

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