benefitsinfo reference 121 53 ge inpatient claim form - endorsement by pan (giro)

8/12/2019 BenefitsInfo Reference 121 53 GE InPatient Claim Form - Endorsement by PAN (GIRO)

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GROUP HOSPITAL & SURGICAL CLAIM FORM(Please attach all final detailed and original bills/invoices/receipts and other relevant documents

with this form and submit not later than 30 days from incurred date)

THE GREAT EASTERN LIFE ASSURANCE COMPANY LIMITED(Registration. 10! 00011")

Pan Resources Pte Ltd (#nsurance $ro%er)

Hospta!saton " Pre & Post #!!s Outpatent Speca!st

Please answer all the relevant questions below (in BLOCK LETTERS) PART A $ CLAIMANT% PATIENT DETAILS

Name of Emlo!er"Poli#!hol$er

%rou Poli#! No

Name of Emlo!ee(as in NR&C)

Plan T!e"Room ' Boar$Entitlement

Emlo!ee & ire ate NR&C"BC" *in"

Passort No &nsuran#e

Commen#ement ate

%en$er +ale " *emale ,

ate of Birth("++"----)

esi.nation +arital Status, S " + " " SeLo#ation eartment Conta#t No (O) (R) (+)

E/+ail 0$$ress &f atient is a $een$ant1 lease #omlete below

Name of Patient

(as in NR&C)

O##uation

Relationshi Souse " Chil$ Plan T!e NR&C"BC" *in"Passort No &nsuran#eCommen#ement ate %en$er +ale " *emale ,

ate of Birth("++"----)

PART # $ CLAIM DETAILS

Name ' 0$$ress of Re.ular" *amil! o#tor 0re !ou ma2in. a #laim from other insuran#e#oman!(ies)1 !our emlo!er or an! other arties3

-es No&f !es1 lease state the name of the insuran#e#oman! an$ the oli#! number

(lease submit a #o! of the other insuran#e #oman!4s #laim settlement letter" a!ment vou#her an$ #ertifie$ true #o! of the hosital billsb! other insurer

&f hositalisation is $ue to si#2ness1 lease #omlete questions below

ia.nosis ' S!mtoms ate s!mtomsfirst aeare$

as this #on$ition beentreate$ reviousl 3

-es No ate illnessfirst treate$

T!e of Oeration erforme$(if ali#able)

0$mission $ate of hositalisation "$a sur er "++"---- is#har.e $ate of hositalisation "$a sur er "++"----

Name an$ a$$ress ofatten$in. h!si#ian(Please atta#h a hoto#o! of the%eneral Pra#titioner4s referral letter)

ate of revious treatment

, Please #ir#le as aroriate

Pan Resources 5 Commonwealth Lane1 678/9: One Commonwealth Sin.aore 5; (:=) :=?@ 7;75 *aA> (:=) :=?; 7: (:=) :997


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&f hositalisation is $ue to a##i$ent1 lease #omlete questions below

Pla#e of 0##i$ent

ate of 0##i$ent

es#ribe how it haene$ an$state the eAtent of the inur!

Time of 0##i$ent Fhen an$ where $i$ the first#onsultation for this inur! ta2e la#e3

&s the a##i$ent wor2/relate$3 -es No

PART C $ PAYMENT DETAILS

Please a! benefit amount (eA#lu$in. +e$isave $e$u#tion) to > (ti#2 a##or$in.l!)

Emlo!ee Emlo!er " Poli#!hol$er osital +e$isavePlease a! b!>

Cheque 'N(A() %iro

&f !ou woul$ li2e !our reimbursements to be #re$ite$ into !our lo#al ban2 a##ount1 lease furnish !our ban2 a##ount $etailsbelow if it has not been furnishe$ before

Name of Ban2 Bran#h

Bran#h0##ount No Name of 0##ount ol$er >

&f the ban2 a##ount information above is $ifferent from the ban2 a##ount information !ou ha$ .iven rior to this #laim submission1 lease ti#2 here

& hereb! a.ree an$ #onsent to the use b! The %reat Eastern Life 0ssuran#e Co Lt$ (%reat Eastern Life) of the information rovi$e$ herein for theuroses of a$ministerin. the &nsure$" Poli#!hol$er an$ its affiliatesG me$i#al benefits lan for emlo!ees an$ their eli.ible $een$ants1 in#lu$in. but notlimite$ to rovi$in. the aointe$ Panel of +e$i#al o#tors the sai$ information & also #onsent to %reat Eastern Life obtainin. me$i#al information froman! $o#tor &" m! $een$ant has" have #onsulte$ an$ & authoriHe$ to the .ivin. of su#h information & further a.ree an$ #onsent to the &nsure$"Poli#!hol$er an$" or its affiliates releasin. su#h of m! ersonal information to %reat Eastern Life as is ne#essar! for the above state$ urose & #onfirmthat all information .iven above is true1 #orre#t an$ #omlete an$ hereb! authoriHe %reat Eastern Life to verif! the information with the ban2 #on#erne$ onsent to an$ authoriHe$ that the information .iven above is use$ solel! for the urose of reimbursement of #ertain me$i#al #laims & a.ree that ahoto#o! of this form shall be as vali$ as the ori.inal & un$erstan$ that the #oman! will not be hel$ liable for an! $ama.es1 #osts1 losses or eAensesas a result of the #laims ro#ee$ bein. #re$ite$ into the ban2 a##ount shown above

ate

IIIIIIIII

Name of Emlo!eeNR&C " *in no>

IIIIII

Si.nature of Patient (Parent if atient is un$er 95 !ears ol$)NR&C " *in no>

IIIIIIIII IIIIIISi.nature of Emlo!ee Si.nature of Patient (if ali#able)

ate

IIIIIIIII

Si.nature of Coman!Gs 0uthorise$ Person 'Coman!Gs Stam '*+ Pan Group)

IIIIII

Print Name of Coman!Gs 0uthorise$ Person'*+ Pan Group)

Notes>5 Ori.inal bills an$ re#eit must show the atient4s name1 $ate of treatment1 $ia.nosis an$ must have the atten$in. h!si#ian4s stam an$ si.nature9 Claims for ur#hase of $ru.s must in#lu$e a hoto#o! of the atten$in. h!si#ian4s res#rition? Claims for Se#ialist Outatient Treatment or J/ra!s" laborator! tests must in#lu$e a #o! of the atten$in. h!si#ian4s referral letter; Reimbursement for arove$ #laims will be ma$e aroAimatel! ? months later from $ate of $is#har.e if Letter of %uarantee is use$ (if ali#able)

= *or hositalisation an$" or sur.er! at .ovt" restru#ture$ hositals1 lease submit the $is#har.e summar!" $a! sur.er! form: *or hositalisation an$" or sur.er! at Private" Overseas hositals1 atient nee$ to .et the atten$in. h!si#ian" sur.eon to #omlete the +e$i#al Certifi#ation ofTreatment at own #ost an$ submit to.ether with this form8 Clini#al 0bstra#t 0li#ation1 $ul! #omlete$ b! the Patient (or Parent" %uar$ian or NeAt/of/ Kin) must be submitte$ to.ether with the #laim form@ &f the #oman! a$mits liabilit! an$ ma2es a!ment to the a!ee in$i#ate$ above1 a##etan#e of our %iro a!ment or #heque will $is#har.e the Coman! of all

liabilities in rese#t of this #laim


ersion 9 as at Dan 977@


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benefitsinfo reference 121 53 ge inpatient claim form - endorsement by pan (giro)

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