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    Medicare Insurance Claim Form: Policyholder

    Uploaded by

    tagashii
    This document is an insurance claim form for Medicare insurance. It requests information about the policyholder, claimant/patient, reason for the claim, treating physician, diagnosis, and any other relevant insurance coverage. It also lists the types of documents that must be included to process the claim, such as bills, medical records, test results, and prescriptions. The claimant and policyholder must sign declaring the information is true and consenting to the insurance company obtaining additional medical records if needed to process the claim.

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

    Medicare Insurance Claim Form: Policyholder

    Uploaded by

    tagashii
    130 views2 pages
    This document is an insurance claim form for Medicare insurance. It requests information about the policyholder, claimant/patient, reason for the claim, treating physician, diagnosis, and any other relevant insurance coverage. It also lists the types of documents that must be included to process the claim, such as bills, medical records, test results, and prescriptions. The claimant and policyholder must sign declaring the information is true and consenting to the insurance company obtaining additional medical records if needed to process the claim.

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    This document is an insurance claim form for Medicare insurance. It requests information about the policyholder, claimant/patient, reason for the claim, treating physician, diagnosis, and any other relevant insurance coverage. It also lists the types of documents that must be included to process the claim, such as bills, medical records, test results, and prescriptions. The claimant and policyholder must sign declaring the information is true and consenting to the insurance company obtaining additional medical records if needed to process the claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    130 views2 pages

    Medicare Insurance Claim Form: Policyholder

    Uploaded by

    tagashii
    This document is an insurance claim form for Medicare insurance. It requests information about the policyholder, claimant/patient, reason for the claim, treating physician, diagnosis, and any other relevant insurance coverage. It also lists the types of documents that must be included to process the claim, such as bills, medical records, test results, and prescriptions. The claimant and policyholder must sign declaring the information is true and consenting to the insurance company obtaining additional medical records if needed to process the claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    MEDICARE INSURANCE CLAIM FORM

    POLICYHOLDER (Company/Individual) Written in BLOCK letters or typed.


    Name:

    Address: POLICY NUMBER:

    FAMILY / MEMBER ID:

    Tel No: EMAIL:

    CLAIMANT / PATIENT (If different from above)


    Name (in full):

    Age: NIC No: Profession or Occupation:

    Home Address:

    Phone No: Mobile Phone No: Email:

    ALL QUESTIONS MUST BE ANSWERED OR THE CLAIM WILL BE REJECTED.


    Claim is for: (ONE claim form per treatment/illness/and per patient)
    Optical: Glasses, eye correction, optician...
    Dental: Dentist, Orthodontist...
    Out-Patient: Consultations, investigations, prescriptions, therapies and treatment.
    In-Patient: Investigations, operations and treatments relating to ONE condition or childbirth.
    Antenatal care
    Other:

    1. Reason(s) for consultation?


    The symptom(s) or problem(s) that led the Claimant /
    Patient to seek treatment.
    2. Please provide:
    a) Name, address and Tel No of the doctor who
    attended you. (If not CLEARLY indicated on the
    documents.)
    b) Treating Doctor’s Diagnosis
    3. If the claim is consequent upon an accident, please state
    the date and give full details of the accident. If you were
    involved in a road accident, please also provide registration
    numbers of the vehicles, name of third party’s Insurer and
    the Police station where the accident was reported.
    4. If there is any other insurance or provident fund covering
    this illness or injury, please give all relevant details.
    5. Is the treatment in connection with this illness or injury now completed? YES / NO
    If NO, do you intend submitting additional claim(s) for this illness or injury? YES / NO
    HTH025

    Swan General Ltd Swan Centre | 10 Intendance Street | Port Louis, Mauritius
    T (230) 207 3500 | F (230) 211 2031 | W swanforlife.com | BRN: C06000922
    DETAILS OF DOCUMENTS INCLUDED
    ALL documents must be Originals where possible.
    If any document is missing or unreadable, the claim will be rejected.
    YOU must make sure that the doctors, other therapists and pharmacists write clearly.

    IN-PATIENTS
    All documentation, investigations, treatments and a Medical Report about your admission.
    OUT-PATIENTS
    Doctors receipt(s)/report stating the diagnosis CLEARLY. Writing must be readable.
    Doctors prescription(s).
    Pharmacy receipts. Typed or CLEARLY written.
    Doctors request letter for ALL tests done.
    Doctors referral letters for physiotherapy or other therapies.
    Breakdown of costs of all blood tests and other investigations.
    Optical: Optician’s prescription for new lenses, replacement or else.
    Dental: Detail of procedure(s) done INCLUDING detail of tooth or teeth repaired.
    Please list any other relevant documents below.

    Please find attached bills amounting to Rs being claimed for above treatment.
    (Should you wish to receive your out-patient claim settlement by Electronic Fund Transfer, please contact our Health & Travel
    Department on phone No. 207 3500).
    I/we declare the above particulars are true and correct and undertake to give every assistance within my/our power to deal with
    this claim.
    I hereby authorise my general practitioner, health professional or other relevant medical establishment to provide any health
    details or medical records that may be requested by Swan General Ltd or their appointed representatives.
    I/we understand and accept that in case there is any doubt about this claim, Swan General Ltd reserves the right to have the
    claimant/patient cross examined by another medical practitioner of its choice.

    Date:
    Policyholder’s signature Claimant’s signature

    For office use by Swan’s Medical Officer

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