Medical Reimbursement

Topics: Selangor, Shah Alam, Physician Pages: 3 (266 words) Published: June 18, 2013
Metronic iCares Sdn Bhd
(a subsidiary of Metronic Global Bhd) No 2, Jalan Astaka U8/83, Seksyen U8, Bukit Jelutong, 40150 Shah Alam, Selangor Darul Ehsan, Malaysia. Tel : +6 03-7843 -9459 Fax : +6 03-7847-4304 www.micaresvc.com

NON-PANEL REIMBURSEMENT CLAIM FORM
Personal Detail Company Name Employee Name Patient Name Contact Number Mailling Address : : : : : Self : Employee ID : Employee NRIC : Patient NRIC : Dependant :

Email Address Bank Detail Payee Name Bank Name Bank Account Number Medical Detail No

:

: : :

Clinic / Hospital

Date

Diagnosis

Receipt No

(RM)

REASON / REMARK

:

MC Given

: Yes No

Start Date :

Duration :

Day(s)

Claimed by: I solemnly and sincerely declare that the information provided is full, complete and true. I hereby authorise any physician, nurse or medical staff of the hospital/ GP clinic who has observed or treated me/ my above named spouse/ my above named child to release my/ my above named spouse/ my above named child's medical information and medical history to my employee and Metronic iCares Sdn Bhd for the purpose of processing my medical claim, if any, for the purpose of documentation. I hereby undertake to reimburse my employer or Metronic I Cares Sdn Bhd in the event that my/ my above named spouse/ my above named child's hospitalisation/ clinical cost are not covered by the medical policy of my employer due to any reason whatsoever.

Signature of Employee/ Patient Name : Relationship :

Date

Received by:

Signature of Employer / HR Name : Date :

Company Stamp

For Micares used
Remark:

Claims Status

: Approve : Reject

Approval Amount : RM Reason of reject :

Processed by :

Approved by ;

Signature Name : Date :

Signature Name : Date :

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