Claim Form (Out Patient + Hospitalisation)

Claim Form
IMPORTANT INSTRUCTIONS: (please read them first)

IIIIn order for us to provide You with fast and efficient service, please complete the Form accurately in CAPITAL LETTERS. Photocopies of this from can also be used. Filled forms should be sent to: Claims Department, Allianz EFU Health Insurance, D-74, Block-5, Clifton, Karachi within 30 days of the expense incurred date. Please attach the following with the form: a. Proper itemized bill(s) and payment receipt(s) as highlighted below. These should be issued on the official bill/receipt book of the Hospital/Physician/Surgeon/Pharmacy/Laboratory. Proper hospital bill in original highlighting type of accommodation used (room type) and break up of total bill according to: 1 Room charges 2 Lab tests and Radiology Charges 3 Consultation charges 4 Surgeons fee with details (if any) 5 Operation Theatre Charges (if any) 6 Anesthesia charges (if any) 7 Medicines (used during hospitalization) 8 Other miscellaneous medical expenses like blood & oxygen, etc. b. c. d. e. Laboratory, or Radiology reports along with doctors reference for the same. Itemized bill(s) of medicines purchased supported by Physicians prescription specifying the quantity and respective dosage. Hospital discharge summary / Clinical Summary (in case of Hospitalization). Copy of Birth Certificate (in case of delivery/child birth)
III- If you have any diffficulties filling this form, please call our Customer Relations Dept. at 111-HEALTH (021-111-432584) To Be Completed by the Employee / Policy Holder: Name of the Policyholder: Name of the Employee: Name of Patient: Date of Birth: Exact duration of illness/injury claimed for: Any history of the same/similar illness or treatment in the past?
Name of Patient Nature of illness / Disability & Treatment Received
Policy Number Total Amount Claimed: Rs. NIC Number (if any): Relationship to the Employee:
Yes
No (if yes, please complete the following)

Remarks
Preiod of Disability / Treatment Month Year Duration
In case of Hospitalization: Emergency Treatment or Elective? Date of Admission: Was pre-authorization taken? Date of Discharge: Yes No
Is the patient entitled to any other benefit or compensation from any other source whatsoever? If so name the companies or association, or other source, and give amount of benefit payable by each:
I hereby certify that all answers, and all documents submitted with the claim form are complete and true. I hereby authorize any doctor, hospital, clinic or medical provider, any insurance company or any company, institution or any other person who has any record or information about me and/or of my family members to provide Allianz EFU Health Insurance Limited with the information, including copies of their records with reference to any sickness or accident, any treatment, examination, advice or hospitalization. Any photocopy of this declaration./authorization shall be taken as the original copy.
Declaration / Authorization:
Signature of Patient
(if 18 years or above, otherwise signature of the employer)
Signature & Seal of the Employer

(For Corporate Schemes only)
Date
To Be Completed by the Attending Physician/Hospital: Patient Name: Primary Diagnosis When did the symptoms first appear? Are you the patients primary physician: Day Yes No Month Year Secondary Dignosis: Month Year
When did the patient first consult you for this complain? Day
Has the patient ever suffered from/been treated for the same OR related condition? If yes, please provide details with dates:
In case of Hospitalization: Name & Address of the Hospital: Phone Number: Hospital Admission Date: Emergency Treatment or Elective? Details of Surgical, Gynecological or Obstetrical procedure performed, (if any): Type of Anesthesia Used (regional/general): Is further treatment anticipated? Yes No (If Yes, pl. explain ____________________________________) Fax Number: Discharge Date:
I, hereby certify that my answers to the foregoing questions are correct and true, to the best of my knowledge and belief. Signature & Stamp of the Attending Physician: Name & Address: Phone Number: Credentials/Qualifications: Fax # Date:
For Allianz EFU Health Insurance Use Only

Policy Number: Claim Number: Claim Received On: Claim Approved By: Certificate Number: Authorization Number Claim Entered By: Claim Cheque Dispatched On:
04/05/PDF
Allianz EFU Health Insurance Limited

Pakistans First Specialized Health Insurer
D-74, Block5, KDA Scheme # 5, Clifton, Karachi-75600. Phone: 111-HEALTH (111-432584); Fax: (92-21)586-4020

Claim Form (Out Patient + Hospitalisation)

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Claim Form (Out Patient + Hospitalisation)

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Claim Form

IMPORTANT INSTRUCTIONS: (please read them first)

No (if yes, please complete the following)

Preiod of Disability / Treatment Month Year Duration

(if 18 years or above, otherwise signature of the employer)

Signature & Seal of the Employer

For Allianz EFU Health Insurance Use Only

Allianz EFU Health Insurance Limited

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