Get Askari Health Insurance Claim Form

CLAIM FORM o g askari health The health insurance programme For Medical Reimbursement Claims Organization Name Employee Name Designation Folio /Credit Letter Contact No. Office Address Patient Name Patient Age Relation with Employee Sex M / F OUT DOOR TREATMENT OPD Please attach itemized Bills Original Prescriptions Lab. Test Reports and Original Receipts Name of Clinic / Hospital and Doctor Date of Visit Consultation Fee Rs. Cost of Medicine Rs. Cost of Investigation / Lab. Test Rs. Total Cost Rs. SPECIALIZED INVESTIGATION Name of Hospital / Institution Referring Specialist / Consultant Please tick which ever is applicable MRI Magnetic Resonance Imaging ERCP Endoscopic Retrograde Cholangio-Pancreatography CAT SCAN Computerized Axial Tomography Date of Intimation ANGIOGRAPHY NUCLEAR SCAN Date of Approval HOSPITALIZATION / DREAD DISEASE / MATERNITY Name of Treating Physician / Surgeon Date of Admission Date of Discharge DREAD DISEASE MATERNITY Ante-Natal Natal Post-Natal Please mention if Normal C-Section D C Abortion etc* MEDICAL SURGICAL Diagnosis / Procedure Room Charges O. T / Labor Room Charges Cost of Anesthetist Investigation Lab. Charges Consultant / M. O Visit Charges Other Cost of Surgeon Name Signature Seal / Stamp of Doctor / Hospital / Institution For Office Use Only Sanctioned Amount EMPLOYEE S SIGNATURE Outstanding Amount Date Not Payable Amount Sanctioned Authority Head Office 4th Floor AWT Plaza The Mall Rawalpindi. Test Reports and Original Receipts Name of Clinic / Hospital and Doctor Date of Visit Consultation Fee Rs. Cost of Medicine Rs. Cost of Investigation / Lab. Test Rs. Total Cost Rs. SPECIALIZED INVESTIGATION Name of Hospital / Institution Referring Specialist / Consultant Please tick which ever is applicable MRI Magnetic Resonance Imaging ERCP Endoscopic Retrograde Cholangio-Pancreatography CAT SCAN Computerized Axial Tomography Date of Intimation ANGIOGRAPHY NUCLEAR SCAN Date of Approval HOSPITALIZATION / DREAD DISEASE / MATERNITY Name of Treating Physician / Surgeon Date of Admission Date of Discharge DREAD DISEASE MATERNITY Ante-Natal Natal Post-Natal Please mention if Normal C-Section D C Abortion etc* MEDICAL SURGICAL Diagnosis / Procedure Room Charges O. Cost of Medicine Rs. Cost of Investigation / Lab. Test Rs. Total Cost Rs. SPECIALIZED INVESTIGATION Name of Hospital / Institution Referring Specialist / Consultant Please tick which ever is applicable MRI Magnetic Resonance Imaging ERCP Endoscopic Retrograde Cholangio-Pancreatography CAT SCAN Computerized Axial Tomography Date of Intimation ANGIOGRAPHY NUCLEAR SCAN Date of Approval HOSPITALIZATION / DREAD DISEASE / MATERNITY Name of Treating Physician / Surgeon Date of Admission Date of Discharge DREAD DISEASE MATERNITY Ante-Natal Natal Post-Natal Please mention if Normal C-Section D C Abortion etc* MEDICAL SURGICAL Diagnosis / Procedure Room Charges O. T / Labor Room Charges Cost of Anesthetist Investigation Lab. Charges Consultant / M. O Visit Charges Other Cost of Surgeon Name Signature Seal / Stamp of Doctor / Hospital / Institution For Office Use Only Sanctioned Amount EMPLOYEE S SIGNATURE Outstanding Amount Date Not Payable Amount Sanctioned Authority Head Office 4th Floor AWT Plaza The Mall Rawalpindi.