住院及手术索偿表.PDF

HOSPITALISATION SURGICAL CLAIM FORM Please “✓” the below box (Must Select) ✓ ( ) MediSurance Medicare Visa MediCover Health Care HealthSurance Part I - TO BE COMPLETED BY THE PATIENT 1. INSURED DETAILS *Mandatory Name of Insured* Name of Patient* * * Policy No.* Mobile No. (Patient) * ( ) Email (Patient) ( ) If you would like to claim the balance payment of this medical expense under other insurance policies you have with AXA (if applicable), please provide policy details below and indicate the order of preference you would like the claim processed under. AXA ( ) 1. Policy No. Product 2. Policy No. Product 3. Policy No. Product 2. CLAIM INFORMATION Have you had any prior treatment for this or related conditions? (If applicable) ( ) Yes Date (dd/mm/yyyy) ( / / ) Name of Physician Address Are you making any other insurance claim as a result of this hospitalisation/surgery? (If applicable) / ? ( ) Yes Insurance Company Policy No. Please “✓” this box for return of certified true copy ( CTC) of original invoice(s) and receipt(s) after claim processing. ✓ , Note : 1) Certified True Copy will not be returned if the claims are fully reimbursed unless request is for other purpose 2) The originals will not b