Penta Care
Penta Care
Penta Care
To be filled by the patient / Physician PROVIDER NAME: Date of Treatment: DOB : Patient Address: To be filled by the Physician CHIEF COMPLAINT / SYMPTOMS: PATIENT NAME: Member Insurance ID: Patient Tel:
Chronic
Acute
Congenital Condition
B.P
Temp:
HR:
RR:
PR:
I declare that I am the patient's medical practitioner, and that the particulars given are to the best of my knowledge true and correct. Name of the Physician: Signature Date STAMP I hereby authorize any Healthcare provider, Insurer to release any information regarding my medical condition & history to Pentacare for the purpose of determining insurance benefits. Patients Name & Signature: Date:
* Attach all the original invoices, investigation results and medical report, Discharge summary (if Inpatient) along with this form for claims reimbursement subject to policy terms & conditions Pentacare Contact Information: TEL: 04-2946443 FAX: 04 - 2946448