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2024 - Reimbursement List of Requirements

Kaiser International

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Shiena Lou B. Amodia-Rabacal
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127 views1 page

2024 - Reimbursement List of Requirements

Kaiser International

Uploaded by

Shiena Lou B. Amodia-Rabacal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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REIMBURSEMENT CLAIM FORM

NAME OF INSURED EMPLOYEE /


1
POLICY NUMBER
NAME OF SICK 0R INJURED PERSON/
2 POLICY NUMBER
3 RELATIONSHIP TO THE EMPLOYEE
CHIEF COMPLAINTS, HISTORY OF
4 ILLNESS
5 DIAGNOSIS
6 NAME OF HOSPITAL OR CLINIC

7 NAME OF ATTENDING DOCTOR

DATE OF FROM:
8 HOSPITALIZATION/CONFINEMENT TO:
CONTACT NUMBER OF INSURED
9 EMPLOYEE(MANDATORY)
10 TOTAL AMOUNT CLAIMED
MEMBER'S BANK ACCOUNT
11 DETAILS

COMPANY NAME:

List of documents attached (In original copies, please check if attached)

IN-PATIENT OUT-PATIENT EMERGENCY

1. Original receipt and invoice -OR

2. Photocopy of prescription/original copy of official receipt of medicine bought outside

3. Photocopy of Medical certificate / clinical abstract.

4. Photocopy of records of operation ( if with procedure)

5. Photocopy of summarized statement of account.

6. Photocopy of itemized statement of account or charge slip

7. Photocopy of police report or incident report for accident injuries / signed deed of subrogation

8. Photocopy of histopath report

9. Reason of confinement or availment from non accredited hospital,physician or clinic

***ALL DOCUMENTS MUST BE SUBMITTED TO LIAISON DEPARTMENT -KAISER


INTERNATIONAL HEALTHGROUP, INC

Office address: GROUND FLOOR OMNIS PROSPERITY TOWER 377 SEN. GIL PUYAT AVENUE,
MAKATI CITY

02-87771036/ 0917-5509157

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