Maxicare Philippines Form – Fill Out and Use This PDF

The Maxicare Philippines form is an official document provided by the Maxicare Healthcare Corporation for members seeking reimbursement for medical claims. It requires comprehensive information from the member, including personal details, medical history, and a detailed account of the medical services availed, to be submitted alongside original documents within a 30-day period from the date of service. Ensuring that all fields are accurately completed is crucial for the successful processing of a claim. For detailed guidance on filling out this form, click the button below.

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Maxicare Philippines Form PDF Details

Navigating the healthcare reimbursement landscape can sometimes seem daunting, especially when dealing with insurance claims. The Maxicare Philippines Claims Reimbursement Form serves as a crucial tool for members seeking reimbursement for medical expenses incurred. Located at the Maxicare Healthcare Corporation's Claims Department, the form requires submission within 30 days from the date of availment to avoid forfeiture of claims. It meticulously outlines the necessary steps and documentation needed, such as attaching all original documents and ensuring complete and accurate information across various sections like Member General Information and the attending physician's report. The form also specifies different document requirements based on the type of claim—whether outpatient, inpatient, maternity, dental, or optical services are sought. Further emphasizing the form's importance, it includes a certification section where the attending physician attests to the accuracy of provided information, underlining the critical role of honesty and precision in the reimbursement process. Adding another layer of accountability, the form mentions the possibility of audits by Maxicare Healthcare Corporation to validate declarations. What stands out is the explicit instruction that original documents must be submitted, and once submitted, these documents will become the property of Maxicare, highlighting the form's role in the meticulous verification process that underpins claims reimbursement.

Question	Answer
Form Name	Maxicare Philippines Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	maxicare gateway loa, maxicare loa request, maxicare loa form online, member gateway maxicare

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Maxicare Healthcare Corporation

Claims Department, 4th Floor Maxicare Tower, 203 Salcedo Street, Legazpi Village, Makati City

Trunkline: (632)908-6900, Reimbursement Claims Department: (632)553-8833

E-mail: reimbursement@maxicare.com.ph

CLAIMS REIMBURSEMENT FORM

INSTRUCTIONS: Please fill out this form and attach all original documents. This form should be submitted to Maxicare Healthcare Corporation within 30 days from the date of availment ; otherwise, reimbursement of claim(s) declared in this form will be forfeited. Please ensure that all pertinent information are completely accomplished.

M E M B E R G E N E R A L I N F O R M A T I O N

( To be accomplished by the patient/member/representative )

Patient Name:		Patient Maxicare ID No.:
Company:		Contact No. of the Patient:
Home Address:

C 0 1 2 5 1	X X X X X X X X X X X X

Principal Member Name:

Mobile No. of the Principal (Required) :		Email Address of Principal:


CLAIM TYPE (please check):	Out Patient (OP)	Out Patient Medicines	Dental
CLAIM TYPE (please check):	Out Patient (OP)	Out Patient Medicines	Dental

	In Patient (IP)	Maternity	Optical

R E P O R T O F T H E A T T E N D I N G P H Y S I C I A N

( To be accomplished by the attending Physician. This will serve as a Medical Certificate if duly certified and signed by the Physician )

Hospital/Clinic:

Address:

Name of Attending Physician:

Contact No.:

Type of Availment of the Patient:

Availment/Admission Date of the Patient:

Emergency

Elective

Discharge Date of the Patient:

Brief clinical and history and pertinent physical findings of the patient:

Final diagnosis of the patient:

Procedure(s) done (if any) :

IMPORTANT: I swear on my professional oath that all declarations and statements mentioned in this document/form are correct and accurate. I further agree and understand that declarations for the claim(s) stipulated in this form may be subject to audit if deemed necessary by Maxicare Healthcare Corporation.

Signature Over Printed Name	Specialization	License Number	Date Signed
of the Physician

B A S I C R E Q U I R E M E N T S

IMPORTANT REMINDER: Maxicare Healthcare Corporation reserves the right to require additional documents to justify payment of claim(s). Failure to submit complete requirements within the 30-day filing period will lead to disapproval of claim(s). Submission of ORIGINAL COPY of documents is required. All documents submitted relative to the claim(s) shall become property of Maxicare and will no longer be returned.

	OUT PATIENT		IN PATIENT		MATERNITY
1.	Fill out the Claims Reimbursement form.	1.	Fill out the Claims Reimbursement form.	1.	Fill out the Claims Reimbursement form.
2.	Medical Certificate indicating the diagnosis and procedure(s) done (if any).	2.	Medical Certificate indicating the diagnosis and procedure(s) done (if any).	2.	Medical Certificate indicating the diagnosis and procedure(s) done (if
3.	Original BIR registered Official Receipt(s) with TIN.	3.	Original BIR registered Official Receipt(s) with TIN.	any).
4.	Charge Slips or detailed itemized/breakdown of charges (charges per item	4.	Statement of Account (summary of Hospital Bill charges).	3.	Original BIR registered Official Receipt(s) with TIN.
paid).		5.	Charge Slips or detailed/itemized breakdown of charges (charges per item	4.	Statement of Account (summary of Hospital Bill charges).
5.	Police report for cases of assault and vehicular accidents.	paid).		5.	Charge Slips or detailed/itemized breakdown of charges (charges per
		6.	Police report for cases of assault and vehicular accidents.	item paid).
		7.	Operative report (for surgical cases).	6.	Operative report (for surgical cases).
		8.	Clinical Abstract/History.	7.	Clinical Abstract/History.
		9.	Certification of non-availability of medicines from hospital pharmacy and	9.	Certification of non-availability of medicines from hospital pharmacy
		original prescriptions signed by the attending physician (for IP medicines bought		and original prescriptions signed by the attending physician (for IP
		outside the hospital).		medicines bought outside the hospital).

	OPTICAL		DENTAL		OUT PATIENT MEDICINES
1.	Fill out the Claims Reimbursement form.	1.	Fill out the Claims Reimbursement form.	1.	Fill out the Claims Reimbursement form.
2.	Medical Certificate indicating the diagnosis.	2.	Medical Certificate indicating the diagnosis and procedure(s) done, if any,	2.	Medical Certificate indicating the diagnosis.
3.	Original BIR registered Official Receipt(s) with TIN.	including tooth number.		3.	Original BIR registered Official Receipt(s) with TIN.
4.	Prescription for eye glasses or contact lens (with name of patient, date,	3.	Original BIR registered Official Receipt(s) with TIN.	4.	Detailed/Itemized breakdown of charges.
eye grade, name of doctor, license number, and TIN).		4.	Detailed/Itemized breakdown of charges.	5.	Prescription for medicines purchased (with date, name of patient,
5.	Detailed/Itemized breakdown of charges.			prescribing doctor, license number, TIN, and details of medicines -
				name, dosage, and quantity).

IMPORTANT: I agree and understand that personal or excess charge(s) shall be subject to off-setting against the member's reimbursable claim. Personal or excess charges are non-coverable availments of the member based on the account's/member's existing healthcare program, but were initially accommodated and paid for in advance by Maxicare Healthcare Corporation. By signing below, I hereby agree to the terms and conditions contained in this Claims Reimbursement Form and related documents.

TOTAL AMOUNT OF CLAIM(S):

Signature Over Printed Name of the Claimant

Date Filed

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This document needs some specific information; to guarantee accuracy, please make sure to heed the guidelines further on:

1. Start filling out your maxicare loa with a number of necessary fields. Get all of the important information and be sure there's nothing missed!

Step number 1 in filling out membergateway maxicare

2. Once your current task is complete, take the next step – fill out all of these fields - IMPORTANT I swear on my, Signature Over Printed Name, of the Physician, Specialization, License Number, Date Signed, B A S I C R E Q U I R E M E N T S, IMPORTANT REMINDER Maxicare, OUT PATIENT, IN PATIENT, MATERNITY, Fill out the Claims Reimbursement, Fill out the Claims Reimbursement, Fill out the Claims Reimbursement, and Medical Certificate indicating with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Ways to fill out membergateway maxicare stage 2

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Maxicare Philippines Form – Fill Out and Use This PDF

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