Maxicare Philippines Form PDF Details

If you are looking for accessible health care in the Philippines, look no further than Maxicare. Whether you need medical insurance coverage or assistance with filing taxes and pin registration forms, Maxicare has got you covered. In this blog post, we'll take a closer look at the Maxicare form that is required to access the benefits of the system and outline how to complete it properly. Keep reading to make sure all your Philippine healthcare needs are handled quickly and effectively!

QuestionAnswer
Form NameMaxicare Philippines Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmaxicare gateway loa, maxicare loa request, maxicare loa form online, member gateway maxicare

Form Preview Example

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

How to Edit Maxicare Philippines Form Online for Free

In case you would like to fill out maxicare loa, you don't need to download any programs - just make use of our PDF editor. To have our editor on the cutting edge of convenience, we work to put into operation user-driven features and enhancements on a regular basis. We're at all times pleased to receive suggestions - help us with revolutionizing the way you work with PDF docs. All it takes is a few basic steps:

Step 1: Click the "Get Form" button above on this webpage to open our editor.

Step 2: The tool provides the ability to modify PDF forms in a variety of ways. Transform it with customized text, adjust what's originally in the PDF, and include a signature - all at your fingertips!

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

It's easy to make a mistake when filling in your IN PATIENT, consequently make sure you take a second look before you'll finalize the form.

Step 3: You should make sure the information is accurate and click "Done" to proceed further. Sign up with us today and easily access maxicare loa, set for download. All changes made by you are saved , which means you can edit the pdf further as required. FormsPal is invested in the privacy of our users; we make sure that all information used in our system remains secure.

Maxicare Philippines Form isn’t the one you’re looking for?

Related Documents