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Medical Claim Form
MEDICAL CLAIM FORM
Please fil all sections (Use separate form per member per visit).
Al claims should be submitted to:
Claims Department/Manager,
AAR Insurance Kenya Ltd.
Real Towers, Hospital Road, Upper-Hill, Ground Floor 0
P.O. Box 41766 - 00100 GPO Nairobi, Kenya N2 1917039 °
For any queries please contact our 24 hour Medical Services helpline at +254 20 2895000 / +254 730 633000 / +254 703 063000
‘or email: medicalservices@aar.co.ke / www.aar-insurance.com
Name:
Date of Birth:
Telephone No. .
DECLARATION: | decae that tothe best of my knowlege ll the infomation proved onthisform i comect. understand that AAR surance wil rel onthe infrmaton
provided a such, | agre and accopt tt this delration gives AAR Insurance ands appcintd represertatives the ct to request pst, present and fiture medial
‘fermation in reltion wo this cl, o anyother veld cn, rom any thd pat inducing provider nd medical practioner | wndersiand thet en deliberate
rixeprecenaton or the omition of any materia facts may ealtn dena he cam an / anceliaton of cove, and posible gal action.
Member / Guardian Signature:
B: CLINICAL INFORMATION (tobe completed by attending Medical Practitioner or Consultant)
Crist visit [| Review (Review visit will be assumed if frst visit is not checked)
Complaints including date of onset:
Diagnosis: .
Attending Practitioner:
Sigh . .- Oficial Stamp:
Please attach a detailed invoice and a copy of referral form
(if patient was referred to your centre) and send to AAR Insurance Kenya
within 30 days of visit for payment purposes.
In case of any admission, send / email this completed form to
AAR Insurance Kenya within 24 hours of admission.
Regulated by the Insurance Regulatory Authority
Insurance
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