Prudential Assurance Co. - Hospital Claim Form Page 3
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4Part II - Medical Certificate (to be completed by the Attending Physician, duly qualified and registered, at the claimant's own expense)
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(
)
Name of Patient
Age & Sex
ID/Birth Cert. No.
/
Admitted
Discharged
Hospital No. / Patient No.
/
DD/MM/YY / /
Time
DD/MM/YY / /
Time
Intensive Care Unit
Yes
from
to
No
DD/MM/YY / /
Time
DD/MM/YY / /
Time
Any home leave taken during the said hospitalization period?
?
Yes, please state the date, time and reason:
,
No
1. a)
Date on which you first saw the patient for this illness or injury?
?
DD/MM/YY
/ /
b)
What were the symptoms the patient complained of at this first consultation?
?
c)
Are you the patient's usual physician?
No
Yes, Medical records date back to
?
DD/MM/YY
/ /
2. According to the patient, how long had he / she been experiencing these symptoms before the first consultation?
?
since
DD/MM/YY
OR for
day(s)
month(s)
year(s)
/ /
3. For this episode, had the patient previously seen other physician for these symptoms?
?
By (name & address of doctor):
Yes,
DD/MM/YY
No
/ /
4. a)
Clinical diagnosis.
b)
When was the patient informed of the diagnosis?
?
By (name & address of doctor):
DD/MM/YY
/ /
c)
How long, in your opinion, has the patient suffered from this disease before his/her first consultation?
?
5. a)
Final diagnosis.
b)
Summary of medical treatment given and tests performed with results.
c)
Surgery performed with dates and surgeon's name.
Remarks: please attach copies of histopathology / endoscopic / diagnostic / laboratory test report/ operation summary etc.
/
/
/
/
(P.T.O.)
chpfrm0103
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