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HclaimForm.pdf.

The document provides instructions for submitting a health claim, including the need for a membership number and the requirement to submit claims within one month of treatment. It outlines the necessary sections to be filled out by both the patient and the service provider, including patient details, treatment details, and declarations. Emergency contact information is also provided for immediate assistance.

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VictorOkafor
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11 views

HclaimForm.pdf.

The document provides instructions for submitting a health claim, including the need for a membership number and the requirement to submit claims within one month of treatment. It outlines the necessary sections to be filled out by both the patient and the service provider, including patient details, treatment details, and declarations. Emergency contact information is also provided for immediate assistance.

Uploaded by

VictorOkafor
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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How to Contact US

01 280 1051 HEALTH CLAIM FORM


Open 24 hours every day
(You will need your
membership number when
you call us) For office use only -Date received:
[email protected]
Important Notes
• Claims for Specialist consultations and any diagnostic procedures must be on the initial recommendation of your GP
except for consultations/treatment given by pediatricians, optometrist and dentist D D M M Y Y Y Y
• Claims, together with original receipts, are to be submi1ed within 1 month of treatment.
Please fill in Section 1 and your provider must fill in Section 2, 3 & 4. In case of Emergencies, you may contact our 24/7 call centre on 01 280 1051.

Section 1 - Patient Details

Surname: First Name: DoB: D D M M Y Y Y Y

Membership Number: Dep Code: Gender: Male Female:

Company/Employer Name: ___________________________________________________________________________________________


Section 2 - Service Provider Details

Provider Name:

Address:

Provider Code:
Section 3 – Treatment Details

Diagnosis: Preauthorization Code:


Encounter/Admission Date: D D M M Y Y Y Y Discharge Date (for admissions): D D M M Y Y Y Y

S/N TARIFF CODE DESCRIPTION OF SERVICE PROVIDED QUANTITY COST


(For drugs, kindly detail dosage and duration)

Section 4 - Provider declaration


Name of Medical Practitioner
I, _______________________________________________________________ certify that the above patient has received the services and treatment
noted on this form; diagnosed and administered by me and this claim is in accordance to the specified treatment.

Provider Stamp Date: D D M M Y Y Y Y


&Signature:
Provider Phone No:

Section 5 - Patient declaration


I hereby declare the above Stated to be true and the details given are correct. I authorize the provider of services to disclose the nature of illness to
Leadway for its confidential use.
Patient’s Signature: Date: D D M M Y Y Y Y

Patient’s Mobile No:

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