Once filled in please email the completed form and suppor ting

documents to claimsubmssions@bomaid.co.bw OR drop off at

your nearest Bomaid office

Membership
Member Claim Submission Form CL1 Number 131133

Please indicate your Health Plan

Access Comprehensive Executive Prestige

Select your level of cover

Core Plus Ex tra Max

Name of principal member

BAME KOONTSE Member ship No. 131133

Date submitted D
22 D 11
M M 2023
Y Y Y Y
Employer group name
SILBOTS Contacts 71305720

Signature B.KOONTSE

Ser vice
Patient Member ship Provider Treatment Amount
name No. Name date claimed Currency

Bame Koontse 131133 sidilega 22/11/2023 350 bwp

To avoid delayed claims processing member s are reminded to ensure the following:

1. That invoices submitted are DE TAILED (ser vices provided are detailed on the invoices, summar y invoices are
not acceptable)
2. That you request pre-authorization from Bomaid for all hospitalisation procedures, appliances, chemotherapy/
radiation therapy, renal dialysis,
3. specialised dentistr y & or thodontic treatment .
4. That proof of payment is attached for each invoice i.e. payment receipts that have ser vice provider’s logo on it
or Bank proof of payment (EF T )
5. That any claim for Rehabilitation therapy and/or appliances has a doctor’s referral letter/motivational repor t and
a therapist’s repor t
6. That any pharmacy prescribed medicines have a doctor s prescription copy attached
7. That claim invoices written in foreign languages are translated to English and cer tified by recognized
institutions, preferably Embassies
8. That proof of travel is attached i.e. stamped passpor t if you sought ser vice outside Botswana
9. That the claim is submitted within 120 days/4 months from time of ser vice

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