Medicard PHILIPINES, INC

MediCard Philippines, Inc. 8th Floor, The World Centre Bldg., 330 Sen. Gil Puyat Avenue , Makati City, 1200 Telephone No.: 884-9999 / Fax Nos.: 810-3855; 848-6454 Claims – RE Form E-mail: [email protected] /Website: www.medicardphils.com Rev. 13 24 August 2015 REIMBURSEMENT CLAIM FORM Kindly fill out ALL information with  marks

DATE FILED : ______TYPE OF CLAIM : OUT PATIENT  IN PATIENT 

PATIENT’S NAME ______MEDICARD ID No. : ______GIVEN NAME , MI, LAST NAME

NAME OF PRINCIPAL MEMBER (IF PATIENT IS A DEPENDENT MEMBER) :

______TIN : ______GIVEN NAME, MI, LAST NAME

COMPANY NAME : ______OFFICE TEL. No.:______

E-MAIL ADDRESS :______TELEPHONE No.:______

HOSPITAL NAME :______DATE OF MEDICAL TREATMENT / CONFINEMENT ______

TOTAL AMOUNT OF CLAIM : P ______

ATTENDING PHYSICIAN’S REPORT In lieu of MEDICAL CERTIFICATE, please have this portion accomplished fully by your ATTENDING DOCTOR

CHIEF COMPLAINTS: ______

LABORATORY OR DIAGNOSTIC TEST REQUESTED: ______

FINAL DIAGNOSIS BASED ON TEST RESULTS IF ANY: ______

PROCEDURE DONE (IF ANY) : ______

I certify to the best of my knowledge and belief that the information provided by me in support of the claim are true and correct.

______SIGNATURE OF ATTENDING DOCTOR OVER PRINTED NAME DATE SPECIALIZATION : ______LICENSE No.: ______------PLEASE CHECK APPROPRIATE BOX FOR PREFERRED MANNER OF RELEASE OF CHECK AND / OR MEMO :

 FOR PICK UP  THRU COURIER / MAIL (PLEASE PROVIDE MAILING ADDRESS)  THRU ACCOUNT OFFICER / BROKER MAILING ADDRESS: ______------WAIVER I ______, hereby consent to the disclosure by MediCard and its representatives of any or all of my medical utilization / (Name of Employee / Patient/ Guardian) diagnosis to my COMPANY, its officers, directors, employees, and/or other authorized agents/representatives, which may result in the course of providing their medical services to me, as PATIENT. I understand that any information which they may acquire and/or receive relating to the said utilization/diagnosis will no longer be covered as confidential/privileged communication upon execution of this waiver. Thus, I hereby waive any claim of confidential/privileged communication against MediCard, its officers, directors, employees, and/or other authorized agents/representatives, its Medical Service Units/Teams and its Accredited hospital/Clinics, and hereby release them from any liability which may arise as an incident of the said disclosure to my COMPANY.

____________ ______SIGNATURE OF PATIENT/EMPLOYEE OVER PRINTED NAME DATE COMPANY NAME

Please complete the following BASIC REQUIREMENTS for REIMBURSEMENT (Failure to do so will invalidate your claim for reimbursement) ** MediCard reserves the right to request for additional documents needed for further evaluation of claim** Out Patient Reimbursement : For Member Financial Assistance: (Death Claim) Fully accomplished Reimbursement Claim Form Fully accomplished Reimbursement Claim Form Cover letter / Incident report (stating the reason for filing of Reimbursement) Certified True Copy of Death Certificate Medical Certificate stating chief complaint and final diagnosis Certificate of Employment of the Principal member Emergency room record MediCard ID or photocopy of any ID of the deceased Original Official Receipts Duly Notarized Affidavit of Next of Kin / Marriage Contract Results of laboratory / diagnostic examination Duly Notarized Attending Physician’s Statement Form (in the absence of the APR , we require Operative Technique (for surgical cases) Morgue or Post Mortem Examination) Police report (for accidents) Police Report (for accidental death) Itemized breakdown of charges Copy of Autopsy report (for death of unknown causes) Subrogation Form (for accidents) In Patient Reimbursement : FOR SELECTED ACCOUNTS ONLY: Fully accomplished Reimbursement Claim Form OP Medicine Reimbursement: Cover letter / Incident report (stating the reason for filing of Reimbursement) History of Present Illness Fully accomplished Reimbursement Claim Form Clinical Abstract Original Official Receipts of medicines Discharge Summary Doctor’s medicine prescription with diagnosis or with a separate medical certificate Original Official Receipt of Hospital bills and/or Prof. fees Itemized breakdown of charges Statement of account Optical Wear Reimbursement: Itemized breakdown of charges or charged slips

Operative Technique (for surgical cases) Fully accomplished Reimbursement Claim Form Police Report (for accidents) Original Official Receipts Certificate of Live birth and/or Marriage Contract (for maternity claim) Prescription for eyeglasses / contact lenses Results of laboratory / diagnostic examinations Itemized breakdown of charges Subrogation Form (for accidents)

GRACE PERIOD FOR FILING OF CLAIMS - 30 days from date of discharge / medical treatment STANDARD PAYMENT PROCESSING - 15 working days from date of receipt of COMPLETE documents