Hospitalization Claim Form

Hospitalization Claim Form
HOSPITAL INFORMATION
Hospital Name
Hospital Phone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Hospital Type
GeneralChronicConvalescent/RehabOther
Admitted Date
MonthDayYear
Date
Hour MinutesAM/PM Option
Discharged Date
MonthDayYear
Date
Hour MinutesAM/PM Option
PATIENT INFORMATION
Patient Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Relevant Name
First NameLast Name
Patient's Relationship to Relevant:
State The Full Details And Nature of The Illness:
Height
Weight
I   First Name   Last Name   hereby warrant that the information given in this claim form is in every respect complete, correct and true.
I authorize any medical practitioner, hospital or other person to provide the information they need regarding my medical history and the injury/illness to which the claim relates. I accept that this consent will always remain in effect and the photocopy or fax of this statement will be accepted as the original. I agree that upon completion and submission of this form and other documents submitted by me, any medical practitioner, hospital or any other person not specifically requested herein may request additional information.
Signed by the claimant or his/her legal representative on this   Date
Signature
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