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Get PH Intellicare Reimbursement Request Form 2013-2024

Fill up this form and attach the required documents) PATIENT'S NAME: PRINCIPAL MEMBER'S NAME: ACCOUNT NO.: COMPANY: E-MAIL ADD: CONTACT NUMBERS: HOSPITAL/CLINIC: DATE OF TREATMENT: REASON FOR REIMBURSEMENT: Cash Basis Non accredited providers Emergency Case TYPE OF CLAIM: OUT-PATIENT IN-PATIENT Others MATERNITY ASSISTANCE OPD MEDICINES/OPTICAL/DENTAL * PLEASE REFER AT THE BACK FOR REQUIREMENTS NEEDED. NOTE: 1. Claims will be processed upon submission of complete requirements. 2. .

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