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    3 views1 page

    Medical Claim Form 2020 Interactive

    Uploaded by

    adammzjin

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    MEDICAL POLICY

    CLAIM FORM
    INSURANCE

    JUBILEE HEALTH INSURANCE LIMITED


    Head Office: DIRECTIONS:
    Jubilee Insurance House, Wabera Street, Please read carefully and fill out the entire form in BLOCK LETTERS.
    P.O. Box 6694 - 00100 GPO, Nairobi, Kenya 1. Complete a separate claim form for each insured individual and for each visit
    Tel: +254 20 328 1000 to the doctor or service provider.
    2. Attach ALL medical bill(s) relating to the claim.
    Call Centre: +254 709 949 000
    a. Make certain, all bills identify the respective patient.
    Email: [email protected] b. All bills should indicate date of treatment, description of service & charges.
    www.jubileeinsurance.com 3. Date and sign the form and ensure that the same is signed and stamped by
    the Doctor/Provider in the space provided.
    4. No claim will be considered if submitted after 90 days from the date of illness.
    5. Providers are advised to cross check the medical card against the national ID
    card for adult patients to ensure that member details are correct.
    6. All invoices must be signed by the client.

    EMPLOYEE (MEMBER) INFORMATION (This is the individual whose name is on the ID card)

    Scheme WELD-CON LTD

    ADAM
    First Name MOHAMED ZUBER JIN Middle Name
    Name ID Surname 23820307
    No.
    PLEASE PROVIDE A MOBILE MONEY ENABLED NUMBER
    Member No.
    675627-00 Mobile 0721779771 FOR REIMBURSEMENTS E.G. M-PESA, AIRTEL MONEY

    P. O. Box
    Postal Code Email [email protected]

    PATIENT INFORMATION

    ADAM
    First Name MOHAMED ZUBER JINMiddle Name
    Patient Name Surname Member No.

    Date of Birth
    04/08/1983
    dd/mm/yyyy Sex: Male Female Relationship: Employee Spouse Child

    KRA PIN PLEASE PROVIDE KRA PIN FOR ADULT PATIENT/MEMBER (THIS IS MANDATORY FOR REIMBURSEMENTS)

    AUTHORISATION FOR RELEASE OF INFORMATION (Patient, parent or guardian must sign below)
    I hereby warrant the truth of the above statements, that I have not withheld from Jubilee Health Insurance Limited any information relating to this claim. I have
    no objection to Jubilee Health Insurance Limited and/or their representatives communicating with the Doctor/Physician or Hospital I have consulted or visited
    and shall submit to any medical examination(s) if so required by Jubilee Health Insurance Limited.

    Signature of patient, parent or guardian (if patient is a minor) Date 06/02/2024

    MEDICAL INFORMATION (To be completed by the Doctor/Physician treating the patient)


    What is the diagnosis for the patient? (Write in BLOCK LETTERS, No Medical Shorthand)

    Is this condition: recurrent? chronic? congenital?

    N/A
    dd/mm/yyyy
    Date(s) of previous treatment for this illness or injury 1. dd/mm/yyyy
    2. 3. dd/mm/yyyy

    Any underlying conditions which could result in this illness or injury?

    Nature of treatment

    Was the patient referred to a specialist? Yes No


    If yes, provide details of the specialist or in case of accidental injury, provide details

    CERTIFICATION BY MEDICAL PRACTITIONER


    ADAM MOHAMED ZUBER JIN
    I certify that the above information regarding Mr/Mrs/Mst/Ms.
    is true, to the best of my knowledge and the expenses incurred are as a result of the accident/illness referred to.

    Name and address of Doctor/Physician DR SURESH JARI

    Qualifications MB. ChB .DDV

    dd/mm/yyyy
    Date 06/02/2024 Signature and Official Stamp
    * Incomplete forms shall not be processed.

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