Medical Claim Form (Reimbursement Only)

Head Office: 05-Saint Mary Park, Gulberg-III, Lahore
Alfalah Customer Care: 042 111-234-222 Fax: +92 042 5774329 & 30
EMAIL: [email protected]
MEDICAL CLAIM FORM (REIMBURSEMENT ONLY)
TO BE FILLED BY THE EMPLOYEE (Incomplete form will not be acceptable) D AT E : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PATIENT’S INFORMATION:: NAME: _____________________________________________ AGE: ______________________________
RELATION WITH EMP: ________________________________ CNIC # : __________________________
EMPLOYEE’S INFORMATION: NAME: _________________________________________ EMPLOYEE ID # : ____________________
OFFICIAL EMAIL: ____________________________________ CONTACT / MOB. #: _________________
PERSONAL EMAIL:___________________________________ HEATH PLAN/RANGE:__________________
BANK ACCOUNT DETAIL: ACCOUNT TITLE :____________________________________ ACCOUNT # : _________________________
EMPLOYER’S INFORMATION: CO. NAME ________________________________________ POLICY #: _________________________
DETAIL OF MEDICAL EXPENSES Hospital Bill NO.-----------------------
SR No DESCRIPTION (for Claimant’s use only) (For AFI Co. use only)
CLAIMED AMOUNT (RS) APPROVED AMOUNT (RS)
1 ROOM CHARGES PER DAY_______ * NO OF DAYS____
2 MEDICINES
3 INVESTIGATIONS (LAB + RADIOLOGY ETC)
4 CONSULTATION
5 OPERATION FEE
6 ANAESTHESIA FEE
7 O.T (OPERATION THEATRE) / LABOUR ROOM CHARGES
8 PRE HOSPITALIZAITON CHARGES
9 POST HOSPITALIZAITON CHARGES
10 PACKAGE / OTHER (Please specify nature of other charges)
Gross Total
Less deductible/over the limit/Non-medical items/others if any.
TOTAL CLAIMED AMOUNT
MEDICAL CERTIFICATE
TO BE FILLED BY TREATING DOCTOR (Claim will not be processed for payment without filling the Medical Certificate)
PATIENT'S NAME : _________________________ AGE: ________ HOSPITAL REFERENCE NO (PATIENT’S FILE #):____________________
DATE OF ADMISSION:_____________________________________ DATE OF DISCHARGE: ________________________________________
____________________________________________________________________________________________
DATES OF ILLNESS / ACCIDENT / INVESTIGATION / TREATMENT
____________________________________________________________________________________________
____________________________________________________________________________________________
FULL PARTICULARS OF THE ILLNESS /REASON OF
HOSPITALIZATION ____________________________________________________________________________________________
____________________________________________________________________________________________
DID THE PATIENT SUFFER FROM THIS ILLNESS BEFORE?
IF YES, FOR HOW LONG? ____________________________________________________________________________________________
____________________________________________________________________________________________
NAME ,ADDRESS AND TELEPHONE # OF
THE HOSPITAL IN WHICH HE/SHE HAS BEEN TREATED ____________________________________________________________________________________________
___________________________________________________________________________________
NAME & ADDRESS AND TELEPHONE # OF ____________________________________________________________________________________________

THE ATTENDING M.P / CONSULTANT / SURGEON
____________________________________________________________________________________________
SIGNATURES & STAMP OF ATTENDING DOCTOR WITH PMDC #
____________________________________________________________________________________________
CHECK LIST
In support of the above claim, I am enclosing the following documents (Please indicate by tick mark)
MANDATORY DOCUMENTS NEED TO BE ATTACHED Yes No If “NO” Then Describe the Reason
1. Final Hospital Bill with Receipts (Original)
2. Discharge summary indicating final diagnosis
3. Original cash memos of medicines from the hospitals/chemist
supported with proper doctor’s prescriptions
4. Receipt (Original) and pathological/radiological test reports
with proper prescription of the attending medical practitioner/
Consultant and Surgeon.
5. Surgeon certificate stating nature of operation performed and
surgeon’s bill and receipt (if applicable).
6. Attending doctor’s / Consultant’s / anesthetist’s original bill &

receipt (If applicable).
7. Copy of Computerized Birth Certificate (In Case of Delivery /

Child Birth)
8. Copy of Company’s Prior Approval (in non-emergency cases)
9. Copy of CNIC of patient (if patient is adult) & Copy of Health
Card issued by Company.
SPECIAL INFORMATION ABOUT THE CLAIM
PARTICULARS CLAIMANT’S REMARKS HR’S RECOMMENDATIONS
 Reason for Cash Treatment in Panel

Hospital
 Reason for treatment in Non-Panel

Hospital.
 Reason for late submission of the claim
DECLARATION
I hereby agree, affirm and declare that:
(a) The statements/information given/stated by me/us in this claim form is true, correct and complete.
(b) No material information which is relevant to the processing of the claim or which in any manner has a bearing on
the claim has been withheld or not disclosed.
(c) If I have given/made any false or fraudulent statement/information, or suppressed or concealed or in any manner
failed to disclose material information, the policy shall be void and that I shall not be entitled to all/any rights to
recover hereunder in respect of any or all claims, past, present or future.
(d) The receipt of this claim form/other supporting/related documents does not constitute or be deemed to constitute an
agreement by the Company of the claim and the Company reserves the right to process or reject or require
further/additional information in respect of the claim.
(e) I further declare that in respect of the above treatment no benefits are admissible under any other Medical policy of
Takaful / insurance. I consent and authorize the insurers to seek medical information from any Hospital/Medical
Practitioner who has at any time attended concerning the claim.
________________ ____________ ____________

Employee’s Signature Employer’s Signature & Stamp

Medical Claim Form (Reimbursement Only)

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Head Office: 05-Saint Mary Park, Gulberg-III, Lahore

MEDICAL CLAIM FORM (REIMBURSEMENT ONLY)

TO BE FILLED BY THE EMPLOYEE (Incomplete form will not be acceptable) D AT E : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

PATIENT’S INFORMATION:: NAME: _____________________________________________ AGE: ______________________________

RELATION WITH EMP: ________________________________ CNIC # : __________________________

EMPLOYEE’S INFORMATION: NAME: _________________________________________ EMPLOYEE ID # : ____________________

OFFICIAL EMAIL: ____________________________________ CONTACT / MOB. #: _________________

PERSONAL EMAIL:___________________________________ HEATH PLAN/RANGE:__________________

BANK ACCOUNT DETAIL: ACCOUNT TITLE :____________________________________ ACCOUNT # : _________________________

EMPLOYER’S INFORMATION: CO. NAME ________________________________________ POLICY #: _________________________

DETAIL OF MEDICAL EXPENSES Hospital Bill NO.-----------------------

3 INVESTIGATIONS (LAB + RADIOLOGY ETC)

7 O.T (OPERATION THEATRE) / LABOUR ROOM CHARGES

8 PRE HOSPITALIZAITON CHARGES

9 POST HOSPITALIZAITON CHARGES

10 PACKAGE / OTHER (Please specify nature of other charges)

Less deductible/over the limit/Non-medical items/others if any.

TOTAL CLAIMED AMOUNT

DATE OF ADMISSION:_____________________________________ DATE OF DISCHARGE: ________________________________________

NAME & ADDRESS AND TELEPHONE # OF ____________________________________________________________________________________________

6. Attending doctor’s / Consultant’s / anesthetist’s original bill &

7. Copy of Computerized Birth Certificate (In Case of Delivery /

SPECIAL INFORMATION ABOUT THE CLAIM

PARTICULARS CLAIMANT’S REMARKS HR’S RECOMMENDATIONS

 Reason for Cash Treatment in Panel

 Reason for treatment in Non-Panel

 Reason for late submission of the claim

________________ ____________ ____________

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PATIENT’S INFORMATION:: NAME: _______________ AGE:

RELATION WITH EMP: ______ CNIC # :

EMPLOYEE’S INFORMATION: NAME: _____________________ EMPLOYEE ID # :

OFFICIAL EMAIL: ____________________ CONTACT / MOB. #: _

PERSONAL EMAIL:_________________ HEATH PLAN/RANGE:

BANK ACCOUNT DETAIL: ACCOUNT TITLE :____________ ACCOUNT # : _

EMPLOYER’S INFORMATION: CO. NAME ________________ POLICY #: _

DATE OF ADMISSION:_ DATE OF DISCHARGE: ____

____