Claim NO.

DATE & TIME SUBMITTED:

RECEIVED BY:
DATE & TIME RECEIVED

Please note of the following ensure smooth processing of your claim:

1. Member should fill up Part I of this REIMBURSMENT CLAIM FORM and affix signature.
2. Request attending Physician to fill-up Part II (lower portion) of this form or attach a "detailed" Medical Certificate from the Physician.
3. Prepare the following supporting documents needed to process or evaluate your claim reimbursement:
Original official receipt (s) of Professional Fees, Hospital Fees and Diagnostic Procedure (s);
Hospital Statement of Account (SOA) where member was confined or treated.
Individual charges slips or itemized breakdown of charges to support Hospital SOA.
Additional documents for confinement cases or inpatient clams: Admitting History Report and Patient's Medical Abstract to be
obtained from the Medical Records section of the hospital.
For surgical cases: operative report and histopathological report.
For outpatient Medical Procedure or Diagnostic exams: Request of the procedure or diagnostic exam (s), and Result(s) of the -
- procedure or diagnostic exam (s)
4. Attach photocopy of any valid ID with signature and picture (e.g. Company ID)
5. Submit fully accomplished Reimbursement Claim Form together with complete documents within 90 days from availment of services to:
ROYALE MARINERS’ HEALTHCARE CONSULTANCY INC.
Unit 705, 7/F Park Trade Center, 1716 Investment Drive, Madrigal Business Park, Ayala Alabang, Muntinlupa City, 1780
Kindly note that missing any document mentioned above will delay or invalidate the processing of your claim reimbursement.

Part I : TO BE ACCOMPLISHED BY MEMBER

*NAME OF PATIENT *DATE OF BIRTH

PRINCIPAL VESSEL: DEPENDENT. Please state name of principal member

HOME ADDRESS: *CONTACT NUMBERS:
RESIDENCE
MOBILE
OFFICE ADDRESS: OFFICE

If claim is approved : REASON FOR REIMBURSEMENT:

Metrobank Branch Emergency case in non-accredit hospital
Allottee Account Name Medicine/s not available during confinement
Allottee Account Number Without accredited providers in the area
OTHERS: pls. specify

DECLARATION
I acknowledge that Company's liability is limited only to that is provided for in the Medical Benefit Package and that this claim may be denied by
the Company.
I certify that the foregoing information are true and correct to the best of my knowledge and hereby attest that all doctors or other persons who
treated me and all the hospital/s or institution/s, to furnish all copies of the records regarding this claim.
*
Name & Signature of Claimant
* Date signed:

Part II : TO BE ACCOMPLISHED BY THE ATTENDING PHYSICIAN

*NATURE OF ILLNESS (FINAL DIAGNOISIS) *NATURE OF PROCEDURE, if any. (Please describe fully)

*CONFINEMENT OR TREATMENT DATES: Has patient been previously confined in a hospital or treated for
this
FROM TO condition or any related condition? YES NO
If yes, please indicate date or availment

I hereby certify that the information provided are true and correct to the best of my knowledge and belief. I further agree that audit/checks
may be conducted for this claim.

Signature over Printed Name of the Attending Physician *Contact Number/s:

*License No. MOBILE
*Date signed OFFICE