Medical Treatment Claim Form

Medical Treatment Claim Form
Note: Please complete this form accurately and make sure that required fields are filled to avoid delay in processing the claim.
Date Filed
MonthDayYear
Date
Member Information
Membership ID
Policy Number
Full Name
First NameMiddle NameLast Name
Age
Date of Birth
MonthDayYear
Date
Gender
Phone Number
Area CodePhone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Is the member the same as the patient?
Patient Information
Full Name
First NameMiddle NameLast Name
Age
Date of Birth
MonthDayYear
Date
Gender
Relationship to the member
Claim Details
Are the injuries caused by accident?
Details of the accident
Please be specific about the details.
Are the injuries related to your job?
Details of the injury
Please be specific about the details.
Claim Information
Rows Date (M/D/Y) Diagnosis Treatment Medications Others Total Charge
1
2
3
4
5
6
7
8
9
Total Amount
Member/Patient Signature
Clear
Date Signed
MonthDayYear
Date
- Medical Data
- Chief Complaints
- Date symptoms presented
  MonthDayYear
  Date
- Based on the medical history of the patient, was the patient previously hospitalized for the same illness or related?
- Please provide details of the past treatment
- Medical Diagnosis
- Medical Provider Details (Hospital/Physician)
- Physician Name
  First NameLast Name
- Hospital Name
- Hospital Phone Number
  Area CodePhone Number
- Hospital Email
  example@example.com
- Hospital Address
  Street Address
  Street Address Line 2
  CityState / Province
  Postal / Zip Code
- Physician Signature
  Clear
- Date Signed
  MonthDayYear
  Date
- Should be Empty:

Rows	Date (M/D/Y)	Diagnosis	Treatment	Medications	Others	Total Charge
1
2
3
4
5
6
7
8
9

Medical Treatment Claim Form

Member Information

Patient Information

Claim Details

Medical Data

Medical Provider Details (Hospital/Physician)