INPATIENT AND SURGICAL CLAIM FORM

This form should be completed and shall only be applicable for 1 (one) patient and must be fully completed and signed by the insured person or
his/her parents for minor patient.

This form should be filled-in correctly, completely, and clearly.

The claim can only be further examined and processed if all supporting documents of claim submission have been filled, completed, and attached.
The supporting documents of claim submission shall include: Guarantee Letter; Claim Form; Original Receipt and its details bearing the name of
patient, date of treatment, and amount of charged; detailed report of medical prescription, laboratory / radiology result and Histopathology Report.
diagnostic results of supporting examinations, and Histopathology.

Filled by the insured person or by his / her parents for minor patient.

EMPLOYEE DATA PATIENT DATA

Suami/husband

If another insurance policy covers this treatment, please state the name of the Company, address, and telephone number :

I declare that I have read, understood and answered all the the questions above completely and correctly. I hereby authorize any physician, hospital,
clinic, public health centre, insurance company, legal institutions, personal or other organizations that has any records or information on my health
conditions to inform (NAME OF COMPANY) or its authorized party, any explanation on my health conditions. Copy of this statement should be valid
and legal as the original.

Signature, name of employee / Employee's family

 To be filled-in by the Attending Physician and Surgeon.

I do certify that I personally examined the illness / injury sustained by the patient mentioned below.

Admission Date

How long has the patient suffered from the symptoms?

Indications for Hospitalization

Diagnosis

Has the patient ever been treated for this symptoms ? If yes, please explain.

For a reffered patient, please state the name of the referring physician and medical institution:

Procedures or Surgery during treatment

Are the above illness/conditions caused by or related to

Cosmetics or Aesthetics

If the treatment is due to occupational accident please state

Recovered Dead

I declare that the information above is true to the best of my knowledge and belief.