Norton & Harrison Warehouse Complex

Sheridan cor. Pines St., Brgy. Highway Hills,

Mandaluyong City

Tel : +632 8982 3376

Web: www.i-fern.com

FINANCIAL ASSISTANCE CLAIMS REIMBURSEMENT FORM

CLAIMANT’S NAME : _______________________________________
PRIMARY ACCOUNT NAME : _______________________________________
CONTACT NUMBER : _______________________________________
DATE : _______________________________________

REQUIREMENTS FOR REIMBURSEMENT

Please attach the following documents:
[ ] All original official receipts or certified true copy of receipts from the Hospital
[ ] Medical / Clinical Abstract / Medical Certificate
[ ] Itemized statement of account with ER Charges / ER Assessment
[ ] Police Report / Incident Report
DETAILS OF ACCIDENT / INJURY
DATE PLACE
NATURE OF ACCIDENT/INJURY
DESCRIPTION OF ACCIDENT/INJURY –
How did it occur?
PLACES CONFINED
Hospital From ____________________ To _____________________
House From ____________________ To _____________________
ATTENDING PHYSICIAN’S NAME LICENSE NO.
CLAIMANT’S DECLARATION

I, __________________________________, hereby authorizes and holds harmless I-FERN Corporation

for the access and disclosures of information related to this claim.

_______________________________
SIGNATURE OVER PRINTED NAME

Date___________________________

PHYSICIAN’S STATEMENT
NAME OF PATIENT
CLINIC / HOSPITAL
CLINIC / HOSPITAL ADDRESS TELEPHONE NO.
NATURE OF ACCIDENT / INJURY CONSULTATION DATE
CHIEF COMPLAINT
FINAL DIAGNOSIS

_______________________________
ATTENDING PHYSICIAN’S SIGNATURE
OVER PRINTED NAME

Address ___________________________
License No. ________________________
Date ______________________________