Medibank Private any information as may be necessary to assess this claim. ... Online Members Services â Visit www.med
Complete and mail this claim form to: Hyundai Tiburon Class Action ... Example:
For a $2,000 recovery, you may choose a $2,000 debit card, $2,500 Hyundai ...
EXPENSE CLAIM FORM (FOR ECARES/ULB PERSONNEL). Name ... Project
Description. (Dates, places…) ... credit statement for example). For expenses ...
Claim Form ... submitted with your claim form in order to get reimbursed. ... or
Social Security Number on Form 2441 with your personal income tax return.
If your claim is successful the RAF will pay you directly. ... Kindly attach one of the
following documents to the claim form to enable the RAF to verify the banking ...
DENTAL CLAIM FORM. SEND TO: NATIONAL ELEVATOR INDUSTRY. 'P. 3' II
HEALTH BENEFIT PLAN. CH ECK ONE P 0 BOX 475. ' . [ ] DENTIST S ...
United Nations. Nations Unies. Group medical,hospital and dental Scheme.
Claim for reimbursementof expenses. To be completed by the claimant.
Vanbreda ...
AAA COOPER TRANSPORTATION. PRESENTATION OF CARGO LOSS AND
DAMAGE. MAIL TO: AAA COOPER TRANSPORTATION. P.O. BOX 6827.
kind unless such services, treatment or transportation are covered by ahm OSHC
extras cover. 4 Details of claim Make sure you attach your original account or ...
J400 (Same as ADA Dental Claim Form – J401, J402, J403, J404). To Reorder
call ... 39. Number of Enclosures (00 to 99). Radiograph(s). Oral Image(s). Model(
s) ... I have been informed of the treatment plan and associated fees. ... To the
extent pe
Items 5 - 11 ... I have been informed of the treatment plan and associated fees. I agree to be
responsible for ... To the extent permitted by law, I consent to your use and
disclosure ... Comprehensive ADA Dental Claim Form completion instructions.
J400 (Same as ADA Dental Claim Form – J401, J402, J403, J404) ... To the
extent permitted by law, I consent to your use and disclosure of my protected
health.
Medical GAP Claim ... and Office Visits under Medical GAP Policy). 1. Complete
... A member of the American Fidelity Groups 1-800-662-1 i 13 (toll free) ....
information may be guilty of insurance fraud and subject to criminal and civil
penalb'es.
MEDICAL CLAIM FORM. (Instructions ... IDENTIFICATION NUMBER (Including
all letters & numbers). I CERTIFY ... SAMPLE OF BCBS IDENTIFICATION CARD.
Feb 22, 2010 - 5434 68*. £126.51 for 'lan Travel Services', which we ... £126.51 from 'IAN Travel Services' that I do
For fire/theft incidents, please complete all sections on this form where applicable
, excluding sections F and G. Insured vehicle (continued overleaf). Vehicle ...
Keep a copy of your claim form, receipts, bills and certified/registered mail receipt
. .... (18) Design of a highway (as defined in IC 9-13-2-73), toll road project (as ...
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. .... In
the case of a Medicare claim, the patient's signature ... For example, it may be
necessary to disclose information about the benefits you have used to a hospital
or doctor. ... P
INSTRUCTIONS: Anyone who has a claim for personal injury or property damage
... Keep a copy of your claim form, receipts, bills and certified/registered mail
receipt. 7. .... Design of a highway (as defined in IC 9-13-2-73), toll road project (
as ..
6. Give a rough sketch describing the road map & position of the vehicle at the
time of accident. 7, Driver Details. Name : Relation with Insured : Address : (If ...
NOTE: This form should not be used to make a claim for an administrative ....
example, Central District of California), the bankruptcy debtor's name, and the.
Please use a separate claim form for each patient. Your cooperation in
completing all items on the claim form and attaching all required documentation
will help ...
Before completing this form, please read the following fraud warning for the ....
Upon receipt of revocation or refusal to sign a consent, your dentist or health care
... requesting that the form be translated into Spanish or Chinese, please visit
(example: DELA CRUZ JUAN JR SIPAG). 4. Mailing Address: ... 6. Contact
information: This form may be reproduced and is NOT FOR SALE ... PART IV -
EMPLOYER'S CERTIFICATION (for employed members only). Under the penalty
of law, ...
This form may be reproduced and is NOT FOR SALE
CF1
(Claim Form 1) revised November 2013 Series #
IMPORTANT REMINDERS: PLEASE WRITE IN CAPITAL LETTERS AND CHECK THE APPROPRIATE BOXES. For local availment, this form together with other PhilHealth claim forms and other supporting documents should be filed within 60 days from date of discharge. For availment of benefits abroad, this form together with other supporting documents should be filed within 180 days from date of discharge. Representative of the Health Care Institutions (HCI) shall assist the member/authorized representative in filling out this form. All information required in this form are necessary. Claim forms with incomplete information shall not be processed. FALSE / INCORRECT INFORMATION OR MISREPRESENTATION SHALL BE SUBJECT TO CRIMINAL, CIVIL OR ADMINISTRATIVE LIABILITIES. PART I - MEMBER INFORMATION 1. PhilHealth Identification Number (PIN) of Member:
-
-
2. Name of Member:
3. Date of Birth:
-
-
month Last Name
First Name
Name Extension (JR/SR/III)
Middle Name
Male
5. Sex: Building Name
Barangay
Street
Lot/Block/House/Bldg. No.
City/Municipality
Province
year
(example: DELA CRUZ JUAN JR SIPAG)
4. Mailing Address: Unit/ Room No., Floor
day
Female
Subdivision/Village
Zip Code
Country
6. Contact information: Landline No. (Area Code + Tel. No.): 7. Patient is the member?
Email Address:
Mobile No.:
Yes, proceed to Part III
No, proceed to Part II PART II - PATIENT INFORMATION (To be filled-out only if the patient is a dependent)
1. PhilHealth Identification Number (PIN) of Dependent:
-
3. Date of Birth:
2. Name of Patient:
-
-
month Last Name
First Name
4. Relationship to Member:
Name Extension (JR/SR/III)
Child
Parent
Middle Name
day
year
(example: DELA CRUZ JUAN JR SIPAG)
Male
5. Sex:
Spouse
Female
PART III - MEMBER CERTIFICATION Under the penalty of law, I attest that the information I provided in this Form are true and accurate to the best of my knowledge.
Signature Over Printed Name of Member’s Representative
Signature Over Printed Name of Member Date Signed:
-
Date Signed:
-
month
day
year
If member/representative is unable to write, put right thumbmark. Member/representative should be assisted by an HCI representative. Check the appropriate box: Member
Representative
month
day
year
Relationship of the representative to the member:
Spouse
Child
Parent
Sibling
Others, Specify
Reason for signing on behalf of the member:
Member is incapacitated Other reasons:
PART IV - EMPLOYER'S CERTIFICATION (for employed members only) 1. PhilHealth Employer No. (PEN):
-
-
2. Contact No.:
3. Business Name:
Business Name of Employer
4. CERTIFICATION OF EMPLOYER:
This is to certify that all monthly premium contributions for and in behalf of the member, while employed in this company, including the applicable three (3) monthly premium contributions within the past six (6) months period prior to the first day of this confinement, have been deducted/collected and remitted to PhilHealth, and that the information supplied by the member or his/her representative on Part I are consistent with our available records. Date Signed: Signature Over Printed Name of Employer / Authorized Representative
