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    Hospitalization Reimbursement Claim Form - Part A

    Uploaded by

    Fahad Mehmood
    The claimant and participant must sign declarations confirming the accuracy of the information provided, and the claimant authorizes the sharing of their medical information with Pak-Qatar Family Takaful Limited to process the claim.

    Copyright:

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

    Hospitalization Reimbursement Claim Form - Part A

    Uploaded by

    Fahad Mehmood
    868 views1 page
    The claimant and participant must sign declarations confirming the accuracy of the information provided, and the claimant authorizes the sharing of their medical information with Pak-Qatar Family Takaful Limited to process the claim.

    Original Description:

    Reimbursement claim form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    The claimant and participant must sign declarations confirming the accuracy of the information provided, and the claimant authorizes the sharing of their medical information with Pak-Qatar Family Takaful Limited to process the claim.

    Copyright:

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

    Hospitalization Reimbursement Claim Form - Part A

    Uploaded by

    Fahad Mehmood
    The claimant and participant must sign declarations confirming the accuracy of the information provided, and the claimant authorizes the sharing of their medical information with Pak-Qatar Family Takaful Limited to process the claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    PakQatarFamilyTakafulLimited

    HeadOffice:SuiteNo.203205,BusinessArcade,P.E.C.H.S.,Block6,
    MainShareaFaisal,Karachi,Pakistan
    TelNo.(9221)438035761.FaxNo.:(9221)4386451

    HospitalizationReimbursementClaimForm

    ;
    ;

    Part

    TobecompletedbythecoveredIndividualMemberonly.
    Donotleaveanyblank,unansweredquestions,datesorsignatures,whereverapplicable.

    TypeofClaim:

    Prehospitalizationexpenses

    Hospitalizationexpenses

    PostHospitalizationexpenses

    Prenatalexpenses

    Deliveryexpenses

    Postnatalexpenses

    ClaimantName:

    Participant(Employer)Name:

    SchemeNumber:
    SchemeStartDate:

    SchemeEnd Date:

    PatientsName:

    PatientsTakafulCertificateNumber:

    DateofBirth:

    Patients Sex:

    Male

    Female

    CNIC Number:

    ResidenceAddress:
    Residence:

    Office:

    Mobile:

    1. Statethenaturemedicalcondition,injury,illness:
    2. Onwhatdatedidthesymptomsfirst occur:

    3. NameandaddressofPhysicianproviderfirst
    consultedduetoabovementionedmedicalcondition:

    4. Hasthepatientconsultedanydoctorfortheabovementionedmedicalcondition?
    IfYes,foreachdoctorandhospitalconsulted,statenameandaddress,treatmentprovided.
    NameofDoctor/Hospital

    DateofConsultation

    ReasonforConsultation

    5. Doesthisclaimisrelatedtoanaccident?

    Yes

    No

    Treatment/Results

    YesNoIfYes,whatisthedateoftheaccident?

    Givebriefdetailofwhereandhowaccidenthappened?

    6. Givedetailsofanyotherhealth,medicalortraveltakaful /
    insurance,workmanscompensation,socialsecurityorother
    medicalbenefitstowhichthepatientmaybeentitled:

    NameofHospital,wheretreatmentavailed:

    DateofAdmission:

    DateofDischarge:

    TotalNos.ofdays

    TotalamountofClaim(InPakRupees):
    DECLARATION&AUTHORIZATION

    I hereby certify that all answers to questions appearing on this form and documents submitted with this form are true and complete to the best of my
    knowledgeandbelief.
    I,theaboveclaimant,herebyauthorizeanydoctor,hospital,,clinic,ormedicalserviceprovider,takaful/insurancecompany,oranyotherinstitution,orany
    person, who has any information or record about me and/or any of my dependents to provide PakQatar Family Takaful Limited with the complete
    informationincludingcopiesoftheirrecordswithreferencetoanysickness,accident,disability,anytreatment,examination,medicalinvestigation,adviceof
    healthcareprovider,.Photocopyofthisauthorizationshallbevalidastheoriginal.

    DateofStatement:

    SignatureofclaimantIndividualMember
    Employeewillcompleteandsignthisformonbehalfofminorchildren

    VerificationbyParticipant/Employer
    I/Weherebycertifythatallanswerstoquestionsappearingonthisformaretrueandcompletetothebestofmy/ourknowledgeandbelief.Weunderstand
    andagreethattheabovestatementshallformthebasisforTakafulcoverage.

    DateofStatement:
    SignatureofParticipant

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