Get Amity Reimbursement Form

Filling out the Amity Reimbursement Form online can streamline your claim process and ensure you receive the reimbursements you deserve. This guide provides step-by-step instructions to help you accurately complete each section of the form.

Follow the steps to successfully complete the Amity Reimbursement Form online.

1. Press the ‘Get Form’ button to access the Amity Reimbursement Form and open it for editing.
2. In Section A, input the medical provider details including the provider license number and the provider name.
3. Navigate to Section B to enter patient details. Fill in the patient name, mobile number, card number, file number (as per card), and date of birth in the format D D / M M / Y Y Y Y.
4. Proceed to Section C to provide claim details. Tick whether the patient is an outpatient or inpatient, and indicate if it was an emergency. Include the pre-authorization number, chief complaint, and symptoms.
5. Specify the date when the patient first experienced similar symptoms in Section C. Also, detail any significant signs, other conditions, and the date of this visit along with the diagnosis.
6. Complete the mandatory ICD code section by selecting the appropriate ICD10 or ICD9 codes and providing the necessary details like congenital conditions, chronic issues, check-ups, and others.
7. In Section D, list the proposed medical management plan, including investigations and or procedures, their codes, descriptions, quantities, types, costs, and the total cost.
8. Provide details of the referral doctor, if applicable, including their name and license number.
9. Sign the patient declaration confirming the accuracy of information and allowing Amity to access related medical information. Include your signature and date.
10. Medical practitioners must also fill in their details in the medical practitioner declaration. Add their name, contact number, license number, and a signature with the date.
11. Finally, review all sections for accuracy, save your changes, and choose to download, print, or share the completed form.

Complete the Amity Reimbursement Form online today to ensure your claims are processed efficiently.