Professional Documents
Culture Documents
Completed claim forms (member’s name, policy number, member number) as written on
insurance card
Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis, symptoms, therapy, treatment, etc
Original payment receipt
Detail of medical expense
Copy of prescription
Copy of laboratory / diagnostic result
Claim form recapitulation
Another supporting documents
Dental Benefit:
Completed claim forms (member’s name, policy number, member number) as written on
insurance card
Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis, symptoms, therapy, treatment
type, configuration of treated teeth, etc
Original payment receipt
Detail of medical expense
Copy of prescription
Copy of laboratory / diagnostic result (dental x-ray or panoramic photo)
Claim form recapitulation
Another supporting documents
Maternity Benefit:
Completed claim forms (member’s name, policy number, member number) as written on
insurance card
Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis symptoms, therapy, treatment, etc
*For antenatal treatment: should be informed gestational age from obstetrician
Original payment receipt
Detail of medical expense
Copy of prescription
Copy of laboratory / diagnostic result
Claim form recapitulation
Another supporting documents
Emergency Outpatient due to Accident:
Completed claim forms (member’s name, policy number, member number) as written on
insurance card
Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis, symptoms, therapy, treatment, etc
Original payment receipt
Detail of medical expense
Copy of prescription
Copy of laboratory / diagnostic result
Claim form recapitulation
Detail Chronology
Valid driving license (if member as a driver)
Policy report letter
Another supporting documents
Completed claim forms (member’s name, policy number, member number) as written on
insurance card
CoB letter from the 1st insurer which informed member name, claim amount, paid amount,
unpaid amount
Certified true copy of supporting documents from the 1st insurer as follow:
-Medical resume (that written by the attending doctor including doctor’s name, stamp, and
signature). The information has to contain medical diagnosis, symptoms, therapy, treatment, etc
-Payment receipt
-Detail of medical expense
-Prescription
-Copy of laboratory / diagnostic result
Original receipt of excess claim if the excess paid by member at the hospital (not guaranteed by
the 1st insurer)
Claim form recapitulation
Another supporting documents