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Medical Aid Form

This document appears to be a medical bill form for Dr. Ajewole's medical practice. It requests information such as the patient's name, ID number, medical aid details, next of kin contact information. The form also has sections for the date of service, description of service using ICD-10 codes, dependent code, and signature. The purpose is to submit medical billing claims to the patient's medical aid provider.

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Joshua Ajewole
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266 views3 pages

Medical Aid Form

This document appears to be a medical bill form for Dr. Ajewole's medical practice. It requests information such as the patient's name, ID number, medical aid details, next of kin contact information. The form also has sections for the date of service, description of service using ICD-10 codes, dependent code, and signature. The purpose is to submit medical billing claims to the patient's medical aid provider.

Uploaded by

Joshua Ajewole
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MEDIBILL FORM DR AJEWOLE MEDICAL PRACTICE

MEMBER INFO
NAME: SURNAME: ID:

CELL:

TEL:

RESIDENTIAL ADDRESS:

CODE

NEXT OF KIN CELL:

MEDICAL AID INFO


MEDICAL AID: OPTION:

MEMEBR NUMBER:

PATIENT NAME: CELL NUMBER: ID:

DATE OF SERVICE AND DESCRIPTION /ICD 10 DEPENDANT CODE SIGNATURE


TARRIF CODE CODE
MEDIBILL FORM DR AJEWOLE MEDICAL PRACTICE

DATE OF SERVICE AND DESCRIPTION /ICD 10 DEPENDANT CODE SIGNATURE


TARRIF CODE CODE
MEDIBILL FORM DR AJEWOLE MEDICAL PRACTICE

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