Allianz @ @ Claim Form Iportanr structions: (pléase read fhiem nfs) + In order for us to provide fast and efficent service, please complete the Form accurate in "CAPITAL LETTERS. Photocopies ofthis frm can ako be used | Filed forms shouldbe sent to: Clams Department, Aliant EFU Health Insurance. D-156, Block, KDA Schemes Cliton, Karachi ‘thin 30 days ofthe expense incurred dat. Please attach the folowing wth the form a. Proper itemized bills) and payment receit() as highlighted below. These shouldbe isued on the offical blfreceipt book of the Hospital Physician/SurgeoryPharmacy/Laboratory. Proper hospital bil in original highlighting type of accommodation used (room type) and break up of total bill according to © Room charges @ Lab tests and Radiology Charges © Consultation charges. @ Surgeons fee with deta (any) ‘Operation Theatre Charges (itany) @ Anesthesia charges (if any) © Medicines (used during hospitalization) © Other miscellaneous medical expenses lke blood & oxygen, etc. Laboratary, or Radiology reports alongwith doctor's reference fo the same. itemized bills) of medicines purchased supported by Physician's prescription spectying the quantity and respective dosage. Hosp dscharge summary incal Summary (in ase of Hospitalization). ©. Copy of Birth Certificate (in case of delivery child bith) UL tf you have any difficulties filing tis form, please call our Clas Dept. at 111-HEALTH (021-111-432568) Approved claim could be seted through diect ban transfer Please provide follwing bank deals for dec bank transfer Name of te Policy Holder: Policy Number Name of the Employee: ont I Name of Patent: Total Amount Claimed: Date of i Relationship tothe Employee Bank NIC Number (tay): Branch: Department NC.No Contact No: Eira Detail of New Born (5 In Case of Delivery /C-Section Claim: Date of Bit ‘Name: Gender: In case of Hospitalization; Emergency Treatment or Elective? Wis preauthorzatin taken? Yes_(1No Date of Admission Date of Discharge: Is the patient entitled to any other benefit or compensation from any other source whatsoever if so name the companies o association, ‘or other source, and give amount of benefit payable by each: Declaration / Authorization: ‘heey ces tht lle, nda Goan sailed withthe dn fom are ape and te ese auto any dota, ep nor medal rove, ny instance compary ot ay company, stuten or ay sherpeson who has any recoré reformation about me enor of my taly members t prone ‘ane EF eth rurance Lined wth he formation red copies fe records wih reeenc any ines or acoder, any eaten, examination ace x hospalztion Ay phoecpy of ths dean sutbaraton shale tale asthe orga copy Signature of Patient Signature & Seal of the Date ese te sete roe TacmensimcsayTe letely filled in by er eee Patient Name ee Gender CI Male LiFemale Name of Hospital Date of Admission Date of Discharge Primary Diagnosis Secondary Diagnosis Presenting Complaints With Duration of tiness Any Associated Disease / Comorbids With Duration Det of Surgical, Gnecological or Obstetrical Procedure Performed (if ay) Indication / Necessity of Performing Surgical Procedure] (SCS, Type of Anesthesia Used: CiGeneral Cltocal (Spinal other: |, hereby certify that my answers tothe foregoing questions are corect and true, othe best of my knowledge and belief, Signature & Stamp ofthe Attending Physician: Name & Address Phone Number: Credentis/ Qualifications: ! For Allianz EFU Health Insurance Use Only ij 1 Policy Number erica Number: 1 1 sn Naber utorzation Number i 1 lair Reeve On ‘chim Emery I | im oped Br ‘Chim Cheque Dispatched On: ; 1 Allianz EFU Health Insurance Limited Pakistan’s First Specialized Health Insurer 1-156, Blocks, KDA Schemes, lito, Kerac-75600, Phone: 111-HEALTH (11452504); Cll Centre: (021) 11-HELP-00 (11435700); Fac (82-21)3586-4020 Email: daims@alianzelu com