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    Medical Reimbursement Form v.09.24.19

    Uploaded by

    Aijei Arcena
    1. This document outlines a claim form and requirements for employees to submit medical reimbursement claims. 2. It lists 5 basic requirements for submitting claims, including original receipts, prescriptions, and details of services. Claims must be for at least PHP 500 and submitted within 30 days. 3. Sections I and II require patient and employee details as well as documentation needed for specific medical services like prescription medicines, dental care, and optical expenses.

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

    Medical Reimbursement Form v.09.24.19

    Uploaded by

    Aijei Arcena
    153 views1 page
    1. This document outlines a claim form and requirements for employees to submit medical reimbursement claims. 2. It lists 5 basic requirements for submitting claims, including original receipts, prescriptions, and details of services. Claims must be for at least PHP 500 and submitted within 30 days. 3. Sections I and II require patient and employee details as well as documentation needed for specific medical services like prescription medicines, dental care, and optical expenses.

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    1. This document outlines a claim form and requirements for employees to submit medical reimbursement claims. 2. It lists 5 basic requirements for submitting claims, including original receipts, prescriptions, and details of services. Claims must be for at least PHP 500 and submitted within 30 days. 3. Sections I and II require patient and employee details as well as documentation needed for specific medical services like prescription medicines, dental care, and optical expenses.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    153 views1 page

    Medical Reimbursement Form v.09.24.19

    Uploaded by

    Aijei Arcena
    1. This document outlines a claim form and requirements for employees to submit medical reimbursement claims. 2. It lists 5 basic requirements for submitting claims, including original receipts, prescriptions, and details of services. Claims must be for at least PHP 500 and submitted within 30 days. 3. Sections I and II require patient and employee details as well as documentation needed for specific medical services like prescription medicines, dental care, and optical expenses.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    CLAIM NO.

    __________________________________
    (to be filled out by APSS Processing Team)
    IMPORTANT:
    1. Please fill-out this Claim Form and place in a sealed envelope together with the required claim documents.
    2. Please indicate Employee Name and Site in the envelope.
    3. Claim amount to be filed should be at least Php 500.00
    4. Incomplete claim documents will NOT be processed. Details provided by the employee through email or phone call will not be accepted.
    Supporting document must be issued by doctor, dentist, hospital or clinic.
    5. Submission of complete claim documents: 30 days from purchase date.

    SECTION I. EMPLOYEE and PATIENT DETAILS


    Patient’s Name: Relationship to Employee:
    Employee Name: CES ID Number:
    Tel./Mobile No. Career Level: Hire Date:
    Company Email: HMO Card No.:
    Concentrix Site: Eastwood Tera Ortigas Cubao UP Ayala

    Cyberwest Taguig Naga CDO Davao Cebu

    SECTION II: BASIC REQUIREMENTS


    A. PRESCRIPTION MEDICINES
     Original VAT registered Official Receipt or VAT registered Tape Receipt (provided that the names of drugs/medicines are indicated)
     Breakdown of PF and description of medicines if bought directly from doctor’s clinic
     Original or Clear Photocopy of Prescription except for Over-The-Counter Medicines (with Patients name; Name and Signature of Physician,
    License Number and Date signed)

    *Basic Immunization for Infants – Limited to BCG, DPT, Hepa A and B, HiB, Influenza, Measles, MMR, Polio, PBC, Rotavirus, Varicella
     Original VAT registered Official Receipt (with breakdown of cost per vaccine and Professional Fee of doctor)
     Photocopy of Baby Book indicating vaccines given

    B. NON-PRESCRIPTION/OVER-THE-COUNTER D. PSYCHIATRIC CARE


    MEDICINES  Original VAT registered Official Receipt
     Original VAT registered Official Receipt or VAT registered Tape  Details of availment such as consults or sessions including
    Receipt (provided that the names of drugs/medicines are assessment test
    indicated)
     For Contraceptives (pills), please provide doctor prescription as
    additional requirement for non-married employees.
    C. DENTAL SERVICES E. OPTICAL
     Original VAT registered Official Receipt (with breakdown of cost  Original VAT registered Official Receipt
    per procedure)  Original copy of Prescription indicating the eye grade of Patient
     Original copy of Prescription indicating the breakdown of cost (with Patient’s name; Name and Signature of Optometrist or
    per procedure and tooth number (with Patient’s name; Name Ophthalmologist, License Number and Date signed)
    and Signature of Dentist; License Number and Date signed)

    A. Prescription Medicines
    FOR APSS USE ONLY:
    B. Non-Prescription Medicines
    ______________________________________________________________
    Received
    Name &by: ……………………………………………………………………..........
    Signature of Employee Date Signed C. Psychiatric Care
    Date: …………………………………………………………………….…………………… Total
    D. Medical
    Dental Reimbursement
    Services
    MRF v.09.24.2019 E. Optical

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