Scribd Logo
Upload

Welcome to Scribd!

  • 24 views

    Claim Form For E-Claiming ENG 2010.ashx

    Uploaded by

    srosberg
    This claim form requests reimbursement for medical expenses from an insurance policy. It contains the policyholder's personal details such as name, date of birth, and policy number. The form allows the policyholder to choose between receiving reimbursement on a credit card, bank account, or check. Bank account details or credit card information can be provided. The policyholder can also choose to have these payment details stored for future claims. Health service details such as date, diagnosis, procedures, and charges can be included. The completed form along with bills should be submitted for processing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Claim Form For E-Claiming ENG 2010.ashx

    Uploaded by

    srosberg
    24 views1 page
    This claim form requests reimbursement for medical expenses from an insurance policy. It contains the policyholder's personal details such as name, date of birth, and policy number. The form allows the policyholder to choose between receiving reimbursement on a credit card, bank account, or check. Bank account details or credit card information can be provided. The policyholder can also choose to have these payment details stored for future claims. Health service details such as date, diagnosis, procedures, and charges can be included. The completed form along with bills should be submitted for processing.

    Original Title

    Claim_Form_for_e-claiming_ENG_2010.ashx

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This claim form requests reimbursement for medical expenses from an insurance policy. It contains the policyholder's personal details such as name, date of birth, and policy number. The form allows the policyholder to choose between receiving reimbursement on a credit card, bank account, or check. Bank account details or credit card information can be provided. The policyholder can also choose to have these payment details stored for future claims. Health service details such as date, diagnosis, procedures, and charges can be included. The completed form along with bills should be submitted for processing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    24 views1 page

    Claim Form For E-Claiming ENG 2010.ashx

    Uploaded by

    srosberg
    This claim form requests reimbursement for medical expenses from an insurance policy. It contains the policyholder's personal details such as name, date of birth, and policy number. The form allows the policyholder to choose between receiving reimbursement on a credit card, bank account, or check. Bank account details or credit card information can be provided. The policyholder can also choose to have these payment details stored for future claims. Health service details such as date, diagnosis, procedures, and charges can be included. The completed form along with bills should be submitted for processing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    Claim Form for e-claiming

    (Please use block letters)

    Please submit this claim form along with your bills to: eclaim@ihi.com

    Personal data of policyholder


    First name(s) S T I G E R I K
    Family name(s) R O S B E R G F E R N A N D E Z
    Date of birth (day/month/year) 0 8 0 1 1 9 6 8 Policy number 8 1 2 5 1 5 1 - 2 0 1 2
    Request for payment by international credit card
    The amount should be reimbursed to: Policyholder

    Other

    The amount should be reimbursed in the following currency

    Please transfer reimbursement to my credit card

    Eurocard / Mastercard Visa JCB

    Card no.
    Expiry date (month/year)

    Please transfer reimbursement to my account

    Name of bank C I T I B A N K F . S . B .
    Address M I A M I , F L 3 3 1 3 1
    BIC / S.W.I.F.T. Code / ABA, if any C I T I U S 3 3 A B A 2 6 6 0 8 6 5 5 4
    IBAN
    Account no. 3 1 0 6 2 5 8 5 0 4
    Account holder S T I G E R I K R O S B E R G F E R N A N D E Z
    Please register my credit card/bank account information for future reimbursement YES NO
    Please send me a cheque

    Payee
    Currency
    If no choice of reimbursement method has been made, ihi Bupa will send a cheque.
    Your choice of reimbursement method cannot be changed after the claim has been processed.

    Details of the service provided (please complete if the information is not provided on the invoices)
    Date of service Diagnosis Full name of insured Description of procedures, medical services and Currency Charges
    supplies furnished

    Please submit this claim form along with your bills to: Total charges
    eclaim@ihi.com Amount paid by the insured
    Balance due to hospital/clinic/doctors, etc.
    Submit by e-mail

    ihi Bupa ● Customer Service ● 8 Palaegade ● DK-1261 Copenhagen K ● Denmark ● Tel: +45 33 15 30 99 ● Fax: +45 33 32 25 60 ● Email: ihi@ihi.com ● www.ihi.com
    Medical Centre: +45 33 15 33 00 / Email: emergency@ihi.com
    ihi Bupa is a trading name of Bupa Insurance Limited. Registered in England No. 3956433. Registered office: Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA, UK
    Bupa Insurance Limited is authorised and regulated by the Financial Services Authority (UK)

    You might also like