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    Adamjee In-Patient Claim Reimbursement Form

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    hashamqazi
    This document is an in-patient claim reimbursement form from Adamjee Insurance for a hospitalization claim, which requires details of the patient, illness, hospitalization period and expenses to process reimbursement for an employee of Telenor Pakistan named Hasham Uddin Qazi for the hospitalization of his wife Fatima Ahmreen for pregnancy from October 2014 to June 2014 at Medici Hospital in Blue Area, Islamabad.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Adamjee In-Patient Claim Reimbursement Form

    Uploaded by

    hashamqazi
    2K views2 pages
    This document is an in-patient claim reimbursement form from Adamjee Insurance for a hospitalization claim, which requires details of the patient, illness, hospitalization period and expenses to process reimbursement for an employee of Telenor Pakistan named Hasham Uddin Qazi for the hospitalization of his wife Fatima Ahmreen for pregnancy from October 2014 to June 2014 at Medici Hospital in Blue Area, Islamabad.

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    Adamjee in-Patient Claim Reimbursement Form

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    This document is an in-patient claim reimbursement form from Adamjee Insurance for a hospitalization claim, which requires details of the patient, illness, hospitalization period and expenses to process reimbursement for an employee of Telenor Pakistan named Hasham Uddin Qazi for the hospitalization of his wife Fatima Ahmreen for pregnancy from October 2014 to June 2014 at Medici Hospital in Blue Area, Islamabad.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views2 pages

    Adamjee In-Patient Claim Reimbursement Form

    Uploaded by

    hashamqazi
    This document is an in-patient claim reimbursement form from Adamjee Insurance for a hospitalization claim, which requires details of the patient, illness, hospitalization period and expenses to process reimbursement for an employee of Telenor Pakistan named Hasham Uddin Qazi for the hospitalization of his wife Fatima Ahmreen for pregnancy from October 2014 to June 2014 at Medici Hospital in Blue Area, Islamabad.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    ADAMJEE INSURANCE COMPANY LIMITED

    IN-PATIENT CLAIM REIMBURSEMENT FORM



    NOTE:
    This form is to be supported with paid receipts, prescriptions and discharge summary* of the hospital in original.
    For settlement of the claim, we request you to please fill in each and every column with as much details as possible.
    Please do not leave any column blank.

    POLICY PARTICULARS:
    Policy No.:
    Name of Company: TELENOR PAKISTAN
    Name of Employee: HASHAM UDDIN QAZI Emp ID# 3196 _____________________
    Name of Patient: FATIMA AHMREEN ____________________________
    Age of Person hospitalized: 29 Relationship with Employee: Wife
    Al # : _________________________________________________________________

    DETAILS OF ILLNESS/CONDITION:
    Date of illness/situation first noticed: [Pregnancy] [October -2014]
    Date of recovery: [Discharged on 25
    th
    June 2014]
    Diagnosis: Pregnancy
    Has the claimant suffered from this illness before? No
    If yes, please give date(s) and details:


    DETAILS OF HOSPITAL:
    Name of Hospital attended: MEDICSI SAUDI PAK TOWER - BLUE AREA
    Name of medical practitioner consulted: DR IFFAT
    Period of confinement: From: To:
    Were any drugs prescribed: Yes/No YES
    If yes, please list the drugs prescribed and administered: List attached with details


    AMOUNT OF CLAIM:
    Please list in the column below all expenses claimed and attach original (not photocopies) of all relevant
    paid receipt supported by relevant prescriptions and original discharge summary*
    NAME OF EXPENSES AMOUNT
    Rs.
    Rs.
    Total Amount (in words): Rupees Rs.
    *Discharge summary means a concise description of the patients hospitalization entered into the medical record,
    including the reasons for admission, findings of laboratory testing and other diagnostic procedures, the discharge
    diagnostic provided by the attending physician upon the patients discharge from the hospital and instructions for the
    patient. BY THE INSURED PERSON & ASSURED
    Page 2 of 2

    (a) To be signed by the Insured Person
    I declare that to the best of my knowledge and belief the statements contained herein are true and
    that all relevant information has been disclosed.


    Date: Signature:

    (b) To be signed by an official of the Assured

    I confirm that at the date of claims the member of whose behalf this claim is made was an eligible
    employee in terms of the policy.


    Date: Signature:

    (c) Declaration by the attending Doctor

    I confirm having treated Mr./Mrs./Miss:
    S/O / D/O
    From / /2013 to / /2013and that the details shown on this form are
    consistent with my own knowledge of the patient.


    Date: Signature:

    CHECK LIST FOR CIENT PURPOSE: Requirement for Reimbursement

    Inpatient Claim Form (filled and stamped by the employer and treating Physician)
    Copy of Wellness card
    Proper itemized hospital original bill with following details
    Room Board charges
    Lab charges with reports
    Pharmacy details with cost.(Receipts should have date, printed name & address of pharmacy
    or stamp of issuer)
    Surgeon, anesthesia and O.T charges (applicable in surgical Procedures)
    Labor room charges (in maternity cases)
    Original Discharge card/Summary
    Detailed breakup of Ancillaries & supplies with cost.
    Birth certificate in case of Delivery
    Provide obstetric sheet record




    Telenor HR Signatory and Stamp

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