Get New Reimform1-frontdoc

Filling out the New ReimForm1-frontdoc is a crucial step in processing your reimbursement claim. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete your reimbursement claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Part I, enter the name of the patient by filling in the Last Name, First Name, and Middle Initial fields. Be sure to also provide the Agreement Number or Member ID, as well as the name of your company and their office address.
3. Next, fill in the contact numbers, including telephone and cellphone numbers. In this section, you will also need to indicate your preferred method of payment for the claim, such as pick-up, mail, or bank account details.
4. Indicate the relationship of the patient, marking whether they are the principal member or a dependent. Provide the birthdate of the patient and check the boxes regarding Medicare and other health insurance coverage, providing details if applicable.
5. If applicable, fill out the information related to any accidents that occurred, including the date, time, and place of the accident, as well as a brief description.
6. Complete the hospital information section by providing the name and location of the hospital where the patient received treatment, and indicate if the treatment was facilitated by PhilCare with a referral letter.
7. In the declaration section, review and affirm the accuracy of the information you provided. Sign and date this section to acknowledge your understanding of PhilCare’s policies regarding claims.
8. In Part II, provide the attending physician with the form for them to fill out their section, including details about hospitalization and treatment.
9. Part III is for your employer to complete. Ensure they provide the necessary details about your employment status during the illness or injury.
10. Finally, gather all required supporting documents, including original receipts and medical statements, and submit the completed Reimbursement Claim Form along with the supporting documents to PhilCare Claims Receiving Personnel.

Complete your New ReimForm1-frontdoc online today to expedite your reimbursement claim.