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Pak Qatar Family Takaful Limited: Hospitalization Reimbursement Claim Form

This document is a hospitalization reimbursement claim form for Pak-Qatar Family Takaful Limited. It requests information from the claimant such as the type of claim, claimant name, patient name, dates of admission and discharge from the hospital, total amount of claim, and details of the medical condition, doctors consulted, and other related insurance benefits. The claimant and participant must sign and date the form to authorize the release of the patient's medical records to Pak-Qatar Family Takaful Limited for processing the reimbursement claim.

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mastermind_asia9389
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
683 views

Pak Qatar Family Takaful Limited: Hospitalization Reimbursement Claim Form

This document is a hospitalization reimbursement claim form for Pak-Qatar Family Takaful Limited. It requests information from the claimant such as the type of claim, claimant name, patient name, dates of admission and discharge from the hospital, total amount of claim, and details of the medical condition, doctors consulted, and other related insurance benefits. The claimant and participant must sign and date the form to authorize the release of the patient's medical records to Pak-Qatar Family Takaful Limited for processing the reimbursement claim.

Uploaded by

mastermind_asia9389
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Pak‐Qatar Family Takaful Limited 

  Head Office: Suite No. 203‐205, Business Arcade, P.E.C.H.S., Block ‐6,  
Main Sharea Faisal, Karachi, Pakistan 
  Tel No. (92‐21) 34311747‐61. Fax No.: (92‐21) 34386451  
 
  Hospitalization Reimbursement Claim Form
; To be completed by the covered Individual Member only. 
  Part  ; Do not leave any blank, unanswered questions, dates or signatures, wherever applicable.

 
  A  
Type of Claim: 

   
Pre‐hospitalization expenses 

Pre‐natal expenses   
 

 
Hospitalization expenses 

Delivery expenses   
 Post Hospitalization expenses

 Post‐natal expenses

 
Claimant Name: 
 
Scheme Number:    Participant (Employer) Name:

  Scheme Start Date:   Scheme End Date:

 
Patient’s Name:  

  Patient’s Takaful Certificate Number:    Patient’s Sex:  Male  Female

  Date of Birth:        CNIC Number:

Residence Address:  
 
Residence:   Office:  Mobile:  
 
1. State the nature medical condition, injury, illness:
 
2.   On what date did the symptoms first occur:
 
3.   Name and address of Physician provider first     
  consulted due to above‐mentioned medical condition:
 
4.  Has the patient consulted any doctor for the above‐mentioned medical condition?    Yes  No 
    If “Yes”, for each doctor and hospital consulted, state name and address, treatment provided.       
Name of Doctor/Hospital  Date of Consultation Reason for Consultation Treatment/Results
         
       
         
       
 
5.   Does this claim is related to an accident?  Yes       No   If “Yes”, what is the date of the accident? 
  Give brief detail of where and how accident happened? 

       
 
6. Give details of any other health, medical or travel takaful /  
  insurance, workman’s compensation, social security or other 
medical benefits to which the patient may be entitled:
 
Name of Hospital, where treatment availed:
 
Date of Admission:            Date of Discharge: Total Nos. of days 
  Total amount of Claim (In Pak Rupees): 

  DECLARATION & AUTHORIZATION
I  hereby  certify  that  all  answers  to  questions  appearing  on  this  form  and  documents  submitted  with  this  form  are  true  and  complete  to  the  best  of  my 
knowledge and belief.  
  I, the above claimant, hereby authorize any doctor , hospital,, clinic, or medical service provider, takaful/insurance company, or any other institution, or any 
person,  who  has  any  information  or  record  about  me  and/or  any  of  my  dependents  to  provide  Pak‐Qatar  Family  Takaful  Limited  with  the  complete 
information including copies of their records with reference to any sickness, accident, disability, any treatment, examination, medical investigation, advice of 
  healthcare provider,. Photocopy of this authorization shall be valid as the original. 

 
Signature of claimant Individual Member
Date of Statement: 
  Employee will complete and sign this form on behalf of minor children

Verification by Participant/Employer
  I/We hereby certify that all answers to questions appearing on this form are true and complete to the best of my/our knowledge and belief. We understand 
and agree that the above statement shall form the basis for Takaful coverage. 
   
Date of Statement: 
Signature of Participant 

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