Intellicare Reimbursement Form PDF Details

Do you need to submit a claim for reimbursement from Intellicare? If so, you'll find the process easy and straightforward with their online or paper forms. Whether you are filing for healthcare expenses like doctor's office visits or non-medical services such as educational instruction, this guide will break down the steps required to correctly complete an Intellicare reimbursement form. Read on for a detailed overview of the information needed, step-by-step instructions, and helpful tips on how to ensure your application is approved quickly.

QuestionAnswer
Form NameIntellicare Reimbursement Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesloa intellicare, online loa request intellicare, how to get loa from intellicare online, how to get loa from intellicare

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REIMBURSEMENT REQUEST FORM (IMPORTANT: Please fill-up this form and attach the required documents)

PATIENT'S NAME

CARD/ID NUMBER

COMPANY

PRINCIPAL MEMBER'S NAME

CONTACT NUMBERS

DATE OF TREATMENT

HOSPITAL/CLINIC

REASON FOR REIMBURSEMENT

( ) OUT PATIENT ( ) IN PATIENT

BASIC REQUIREMENTS:

OUT-PATIENT

 

 

 

IN-PATIENT

 

 

 

MATERNITY ASSISTANCE

1)Fill up reimbursement request form/ Letter of request if form not available

2)Statement of Account from the hospital

3)Itemized Original Official Receipt (w/ TIN#)

4)Medical Certificate

5)Laboratory Result

(if w/ diagnostic procedure)

1)Fill up reimbursement request form/ Letter of request if form not available

2)Statement of Account from the hospital

3)Itemized Original Official Receipt (w/ TIN#)

4)Medical Certificate

5)Operative Record w/ Histopath Result

(if w/ operation)

6)Police Report and Medico Legal Report (if case is secondary to vehicular accident and assaults like mauling or stab wounds)

1)Fill up reimbursement request form/ Letter of request if form not available

2)Statement of Account from the hospital

3)Itemized Original Official Receipt (w/ TIN#)

4)Medical Certificate

5)Xeroxed Birth Certificate with original authentication

6)Delivery Room Record

7)Histopath Result

(if case is abortion/miscarriage)

 

 

 

DENTAL

 

 

 

OPD MEDICINES

 

 

 

 

 

 

1)

Fill up reimbursement request form/

1)

Fill up reimbursement request form/

Letter of request if form not available

Letter of request if form not available

3)

Itemized Original Official Receipt (w/ TIN#)

2)

Itemized Original Official Receipt (w/ TIN#)

4)

Dental Certificate

3)

Doctor's prescription

5)

X-ray Result

 

 

 

 

(if w/ x-rayprocedure)

NOTE:

INTERNMENT ASSISTANCE (death claim)

1)Fill up internment assistance form

2)Fill up Certificate of Attending Physician's form

3)Xeroxed Death Certificate with original authentication

4)Xeroxed Birth Certificate with original authentication

* Deceased * Beneficiary

5)Xeroxed Marriage Contract with original authenticatio

6)Certificate of Employment

7)Latest DTR

8)Police Report and Autopsy (if accidental death)

1.All documents submitted will be returned in case of non-submission of any of the above basic requirements.

2.The company reserves the right to require additional documents to justify payment of claim.

3.The company reserves the right to deny any claim even with the complete submission of basic requirements or any additional documents to further justify the claim.

SIGNATURE OF CLAIMANT

DATE SIGNED

(Signature Over Printed Name)

 

ATTENDING PHYSICIAN'S REPORT

(This will serve as your medical certificate if fully signed/certified by attending doctor) (If medical certificate was issued by attending doctor, this portion can be omitted)

NATURE OF ILLNESS (Final Diagnosis)

NATURE OF PROCEDURE DONE, if any. (Please describe fully)

I certify to the best of my knowledge and belief that the information provided by me in support of the claim is true and correct. I further agree that audits/checks may be conducted for this claim.

NAME OF ATTENDING PHYSICIAN

LICENSE NO.

DATE SIGNED

(Signature Over Printed Name)

 

 

 

Contact number of Attending Physician :

 

 

 

Clinic Address of Attending Physician :