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Get Intellicare Reimbursement Form

ER'S NAME CONTACT NUMBERS DATE OF TREATMENT ( ) OUT PATIENT ( ) IN PATIENT HOSPITAL/CLINIC REASON FOR REIMBURSEMENT BASIC REQUIREMENTS: OUT-PATIENT IN-PATIENT 1) Fill up reimbursement request form/ Letter of request if form not available 2) Statement of Account from the hospital 3) Itemized Original Official Receipt (w/ TIN#) 4) Medical Certificate 5) Laboratory Result (if w/ diagnostic procedure) MATERNITY ASSISTANCE 1) Fill up reimbursement request form/ Letter of request if form not av.

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