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Statement of Claim Form (OP IP CLAIM) (Hospitalization)

This document is a claim form for inpatient or outpatient benefits from Sun Life Grepa Financial. It requests information to be completed in 4 sections by the member, attending physician, and member. The first section asks for member details. The second section asks the physician for patient details, diagnosis, treatment details, medicines prescribed, and their signature. The third section asks for accident details if the treatment is due to an accident. The fourth section requires the member's declaration and signature authorizing the disclosure and processing of personal information for the claim.

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Dreyfus Miciano
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153 views1 page

Statement of Claim Form (OP IP CLAIM) (Hospitalization)

This document is a claim form for inpatient or outpatient benefits from Sun Life Grepa Financial. It requests information to be completed in 4 sections by the member, attending physician, and member. The first section asks for member details. The second section asks the physician for patient details, diagnosis, treatment details, medicines prescribed, and their signature. The third section asks for accident details if the treatment is due to an accident. The fourth section requires the member's declaration and signature authorizing the disclosure and processing of personal information for the claim.

Uploaded by

Dreyfus Miciano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Statement of Claim Form -

Inpatient/Outpatient (IP/OP) Benefit


Sun Life Grepa Financial, Inc.
A joint venture of Sun Life Financial and the Yuchengco Group of Companies
Note: To avoid return of claim form due to incomplete information, please answer all questions.
1 To be Completed by the Member

Member’s Name (Last Name, First Name, M.I.) Relationship to Patient

Name of Company/Insured Group /complete address and contact details

2 To be Completed by the Attending Physician

Patient’s Name (Last Name, First Name, M.I.) Age Sex

Date of Consultation (OP Cases) Date of Confinement (IP Cases)


From To
Diagnosis/Reason

Recommended Lab Test/Other Examination

Treatment/Surgical Procedure (if treatment is maternity related, please give exact date of delivery)

Medicines Prescribed

I hereby declare that to the best of my knowledge and belief, the above information is accurate.
Doctor’s Signature over Printed Name PTR No. License No. Field of Specialization
X

Date of Signing Hospital/Clinic Tel. No.

3 To be Answered Only If Case is Due to Accident

If treatment is accident related, please fill in the following:


Describe the accident: Tell how it happened.

When and Where did the accident happen?

What was the injured person doing when the accident happened?

4 Member’s
Employee’s Declaration
Declaration

I HEREBY CONFIRM that the foregoing statements, including my accompanying statements, are to the best of my knowledge and belief, true,
correct and complete. I hereby authorize any physician or any hospital to furnish and disclose all known facts concerning the claim.
You expressly authorize the collection, processing, use, storage, and destruction of your and/or the life to be insured’s personal and
sensitive personal information and any information related to you and/or the life to be insured’s application and/or insurance poli-
cy as well as its sharing, transfer and or disclosure to any of the Company’s branches, subsidiaries, affiliates, agents, and representatives,
industry associations and third parties such as but not limited to outsourced service providers, external auditors, and local and foreign regula-
tory authorities in relation to any matter including but not limited to those involving anti-money laundering and tax monitoring, review and
reporting, statistical and risk analysis, provision of any products, service or offers made through mail/email/fax/SMS/telephone, customer
satisfaction survey; compliance with court and other lawful orders and requirements.
You hold the Company free and harmless from any liability that may arise from any transfer, disclosure, processing, collection, use, storage
or destruction of said information.
Signature of Claimant Date
X

RSCF.01.15
*RSCF.01.15*

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