Section B-To be {illed in by the ireoling Doclor

L
, 2 l-:ow ong you hove bee. pol,e.r! docior? .

-l
20 Sou,ce olodr sslc. Eme.sencY i l [z
Erecrive/promed orh- l .l

2b. Poi€nr Rcg,sred os lnporienr ii Ourporlenr !

a exod doie &
3 Since how long lhe poiienr s suffering lrom lhe p resenr medico co.d t on? Pleoe stob he ve' i

Wiror is yoJ .liog.oses regor<ling inluryll lnes/med icol cord tion?

L_.. _.
Al u l4t^a-!'
Plecse provrde briei deroil ol sugicc Gyncecoloslcol or Obserlcol procediJre performed (ifonv)

8l t-- U::- * "!' .t l,e a

Pleose rck 6e oppropriore rogord:ng rhe diseose

'- ! sucror ! coNrnecrcwr [] o+tts

corlorNr,qL f l nrrnrtuw -l ] ,svcsLerc tLLlrss r-l CCSMETIC

Pleose p,orlde crlel detoll of treohrenr g ve. cr prescrl6.0:

Btv +t,2 L ,tll o

iienreve, suftered trom or been rreored lor he some d reloled medical condiro.? ]lyes Pleose brielderoils w rh dotes

9. li ccsc ol More.i \, clo m peosc srole expeded dore of dellverv

l0 ki cose ol Cosorioi Seciion, pleose speofy :ts med col iece$h/:

f-
t1 The dore you were I61 consuLted for this condt on

lhe'eby cerlt 60r my onswe6 ro rhe obove q!$rioits ore coned oid rrue ro th-' best oi mv knowedge ond beelr

Nome oi fie Do.rorl

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Address ottne Dodor ) 5;3- J RI o w -oHp .t J ro;^^;;"1 (r-.\.\;..
03J,) a\q Dore .,

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& olreir bcth ln cose o moieriolCiiierence i; found ;r nporienr Clo*i
ovdifg co(ecl .j.riiorion,3 ii'E, e;oonslh;llr,; ol corsul,orr
iNori P
po':'rs
.orr.nd Finol Dtschorge S!r,mcry rncn rhc pcvaenr ol hosprrolzor,on e,oense ,,orld be tre resPc.sihilt/ o' conslhonr &

d NONIPPN Hc6Plbl' he
@nlol on Emergercy rhe porid c@ld r$h ro ony hospibl$he*,ef il is Porr or nor ol porelctublee uolrh ln5u6rce. 'oe
n
EIy{ERGENCY Cr,SfS: ln
rJlOigi@' Dclre" eE'rc E ap'!lizor'6 '1 '1
.no,os nc j,e re ns-@ l F,- 'b!.€d ^ , re , h @ oes d p"*ir.op'ot. c6(@.L o, o C-\oro" cl,o 9e.
bv
^ Dvhogemd/Cl'@l'rrcryadoqc'(€Po4s'co@orJ'b€ed@r
,a.i*o Vr,t,"o t"p" -" lorto1poa6BOgidelEdol/,rc,@o_qtuoool@
l^,,,"*! i,J,l c",a. o**' p.*,prom, olgmol pv*n !@he'lp'',renr eerpr'. opv d hcpib/m;'rcipol V bidl edilicore in @€ of rcremit 'him o'v olis elNnr
cG,*-,,'o.lo e e oluoile F6r rd,e.mo-,rnsr
I he l6dmd s @led fd NOI\IPPN Hcp,rot. h,e cto,s* incuned by he risued will be reimbu.Fd in li€ wf$ rlE ds ol @reI Hdoilok/Rdffoire ond Curffi./ cho€6
PPN HcPibl *€ iisured
NON-EMEiGENC/ CAES: While go ns NONIIMERGENCY Trsmenr 6.9. flonn d surgses or HGFlbllelio wAe@ r@tnsr s ro @il fom
6
*-r-ut't* u1tttti"g eefi n orrh. cbm Fc,m;"d PARI B d,t tiled ria h4rins d@lol. The coim lom olcns wh 5uPpdrins
d@umeib
i", . t* li; t
"J"r;on*f
hos btd @ sb;b be end blub;* neolrh lo opprml. Tle Ccdil teie,6lid tu 30 DAYS, wll be i$!€d b rhe @nem
Hcplolond *,e r@ will be enr ro he cloircnr rre
'o
i- ilffi' i" eilbLs ld H*Pldi-id wil be ribd d rerV
ror'-''^' Hol$' M @+ Fov'md .*ld
be Equi'ed rom rrts
c"#;,;;;;; ""r"* mer'i[!'p wiu be €imbu6ed, ci
p"r*,"."pii_ -** -t,.os och ']ubi*rhe clorss incurred by *E ln$redbil1*::'
bon1e. pompeG ek. l{ he k@rnrenr isM bd tom Nl:)NppN Hc!oL
p.rq r",^ AjlOrigirct Docurenh d;ed b hcp rdeio ${ich rclud* dut lllled lmporied I@m Poi A 8 I oigiml llem,,Ed !: or:l
E.in" -a -"aLlims
o,*t",o" -o,c,n.o, sLq, trrv & ooqM.c repon. oo o(lrolee ircF coo Dc..o,! pesdo s.o'ig_ol pc,\a-E.' wrsl@\,e 'eed"
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r*rttZ,-o'*ir g + *n r-re n c@ oll/oe,nry Cb m, onvo Er €l6Enl d€ure'6 shsld be enl blub:le H<lrf id reimblEmenr

PLEttE NOrE: lncomplele Cldim iorms would norb€ occepEi {or p'oce$ing olpovmenrs
docJmeiE should be oroched w th fi. coims. PhoEoP es ore not occepoble
All originol

ilee HeolJh lnsuronce offices will be ovoiloble on workin

f **-crrr,r*o ororc.r)
Ml ?ND AND 3RD TIOOR, D}79 A5\O PLA7A, SBAMSABAD,
Z4l l_A, IALAZ.AR, KHAN
NO 4895, II]iA]I PLA7A. 56 SI.IAOMAN I ,l,!\IN MUREE ROAD, RAWATPND,
RAOD, PO BOX
KARACHIZ4OOO, PA(IsTAN PO$ OIfICE SHAD]\TIAN, IAHORE TLt: 05l/602900
T[l 02r-35205095 TEI:04235843012 l9
i$ 021-356r 134S, 35610959 FAX:0a2358419i3

lubilee Heollh lnsuronce

Coroorole Office, 2nd Foor, PNSC Bullding, lolozor, M l Khon Rood, Korcc-hl '74000, Poklsion
' o"o-",tO2r)3505,/88510..(021)356- 349.J5641315
f. o.l: n'c@rr o lee\eolt\ co"r