Patient’s Name : Date of Birth ( Date/Month/Year ) :
Company Name : Phone :
Home Address : Phone :
Patient’s Membership No. : Policy holder’s Name :
PATIENT CONSULTATION DETAILS
Name of Clinic / Hospital : Date of Service (Date / Month / Year)
Admission Date (Date / Month / Year ) Time
Discharge Date ( Date / Month / Year) Time
Name of Doctor : GP Specialist Specialization
Have you received any treatment for the same conditions/diagnose within the last 3 ( three ) months : Yes No
Is this claim related to work place accident : Yes No If Yes, explain :
Is this a pre-hospitalization service : Yes No
Expected Date of Admission (Date/Month/Year) Name of the Hospital to be used
Details of Treatment / Procedure :
( If yes, please attach the inpatient request from doctor/hospital )
Is this a post-hospitalization service : Yes No Name of Hospital
Date of Admission ( Date / Month / Year )
Date of Discharge ( Date / Month / Year )
Details of Trearment / Procedure :
(If yes, please attach the discharge letter from doctor / hospital )
CLAIM PAYMENT DETAILS
Please pay my claim in : USD ID Rupiah Currency of Claim Amount of Claim :
Method of Payment : Draft Cheque * Giro * Bank Transfer **
Bank Name : Branch :
Account Number : Currency : Account Name :
Are you entitled to submit the claim to another Insurance : Yes No If Yes, Name of Insurance :
Note: * Payment by cheque / giro will be made only for ID Rupiah, in the name of the Policy holder.
** For payment by bank transfer, the currency of claim must be the same as the currency of your bank account or US Dollar / Rupiah account.
- If no payment / bank details are provided, the payment will be made by Giro in ID Rupiah.
- The exchange rate will be based on the rate applicable on the date of claim payment.
- The claim in Indonesian Rupiah can only be settled in Rupiah.
REMINDER FOR FAST CLAIM PAYMENT !
To ensure your claim is paid promptly, please check :
?? Any receipt you attach for reimbursement must be on the letter head of the Provider or bear the Provider Stamp and submit no longer than 30 days from date of admission.
?? Any receipt that fails to note the name of drug, name of laboratory test, etc will not be paid.
?? Any charge that is not clearly for treatment prescribed by the treating Doctor will not be paid. If it is not clear, make certain you attach original prescription etc. from your Doctor
STATEMENT BY CLAIMANT
I hereby authorize the Plan Administrator, Global Assistance & Healthcare? , to obtain any information they may require, including my medical records from my healthcare provider or from
any other party regarding my medical history, treatments and services given to me or to dependant of my family.
X I declare that the information written in this form (including the attachment) is true.
_____________________________________ Date : ___ / ____/___ _____________________________________
Signature of Treating Doctor Date Month Year Patient’s Signature ( or Parent if patient under 17 years of age )
Clinic / Hospital Stamp Date : ___ / ____/___
Date Month Year
Global Assistance & Healthcare is the Rama HealthCare Plan Administrator
. Issued 16 May 2001