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?
YesNo
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?
YesNo
Details of the accident
Please be specific about the details.
Are the injuries related to your job?
YesNo
Details of the injury
Please be specific about the details.
Claim Information
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

To be filled up by the Medical Provider (Hospital/Physician)
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?
YesNo
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

Member Information