Marriage Certificate Ph - Excel by eek10863

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Marriage Certificate Ph document sample

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									                                     FORTUNE MEDICARE, INC. (HMO)
                            3/F CityState Center, 709 Shaw Boulevard, Pasig City
                                          Tel. Nos. 706-4847 loc.253/255

==================================================================================

CHECK LIST OF REQUIREMENTS
OPD   IPD
 /     /    1. Request letter for reimbursement signed by the member/payor
       /    2. Detailed Clinical Discharge Summary w/ indication of vital signs duly signed by the attending physician
 /          3. Medical Certificate w/ indication of vital signs (for out-patient availment)
       /    4. Operative Record and Histopath Report (if surgery was done)
 /     /    5. Original Copy of Official Receipt/s (for Hospital bills & Dr.'s fee)
       /    6. Statement of Account, Charge Slips and invoice
       /    7. Pharmacist's certification on non-availability of stocks w/ list on meds bought outside
                and Doctor's prescription
 /     /    8. Referral slip by accredited Fortune Care physician if referred to a non-FC physician
 /     /    9. Police Report and Incident Report (for vehicular accident)
 /     /    10. Result of Diagnostic Procedure done (MRI, CT-SCAN, X-RAY, etc.)
       /    11. Hospital's certification of non-availability of room
            12. Birth Certificate for Maternity cases
            13. Death Certificate / Marriage contract


       *OPD - Out-Patient availment
       *IPD - In-Patient availment
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This portion to be filled-up by claimant:


                                    REIMBURSEMENT CLAIM INFORMATION SHEET


DATE RECEIVED


                COMPLETE


                INCOMPLETE                        COMPLETION DATE

NAME OF PAYOR:                                   AGE:
NAME OF PATIENT:                                 AMOUNT BEING CLAIMED:
NAME OF COMPANY:                                 OFFICE TEL. NO.:
RESIDENCE ADDRESS:                               HOME TEL. NO.:
CONTRACT NO.:                                    CONFINEMENT DATE:
HOSPITAL:                                        Accredited Hospital?                  YES          NO
ATTENDING PHYSICIAN:                             Accredited Doctor?                    YES          NO
                                                 With referral fr. FC-Doctor?          YES          NO
                                                 Is Confinement Reported?              YES          NO

REASON FOR CLAIMING:                                                         ITEMS BEING CLAIMED:
   Expired ID/Lost ID                                                               Hospital Bill
   Non-Fortune Care Hospital                                                        Hospital Bill & Professional Fees
       No accredited hospital in the area                                           Professional Fees
       No accredited doctor/specialist in the hospital                              Out-patient consultation
   No available laboratory/diagnostic procedure in the hospital                     Medicines bought outside
   Laboratory diagnostic procedure on cash basis                                    Instrument Fee
   Others:                                                                          Special Diagnostic Procedures:
                                                                                            CT-SCAN
                                                                                            MRI
                                                                                    Others:



                                                                             CLAIMANT (signature over printed name)


            BP:                                  General survey upon admission:
            Heart Rate:
            Pulse Rate:
            Temperature:

								
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