Pentacare Reimbursement Claims Form printable pdf download

Pentacare Reimbursement Claims Form

REIMBURSEMENT CLAIMS FORM

To be filled by the patient / Physician

PROVIDER NAME:

PATIENT NAME:

Date of Treatment:

Member Insurance ID:

DOB :

Patient Tel:

Patient Address:

To be filled by the Physician

CHIEF COMPLAINT / SYMPTOMS:

Date of present onset:

Diagnosis:

Diagnosis Code:

Chronic

Acute

Congenital Condition

Clinical Findings :

B.P

Temp:

HR:

RR:

PR:

Physical Findings:

Details of any investigations Done :

Details of the Treatment Done :

I declare that I am the patient's medical practitioner, and that the particulars given are to the best

of my knowledge true and correct.

Name of the Physician:

Signature

Date

STAMP

I hereby authorize any Healthcare provider, Insurer to release any information regarding my medical

condition & history to Pentacare for the purpose of determining insurance benefits.

Patient’s Name & Signature:

Date:

* Attach all the original invoices, investigation results and medical report, Discharge summary (if Inpatient) along with

this form for claims reimbursement subject to policy terms & conditions

Pentacare Contact Information: TEL: 04-2946443 FAX: 04 - 2946448

Pentacare Reimbursement Claims Form