OUTPATIENT CLAIM FORM - Online Life Insurance Singapore CLAIM FORM ... and whether within or outside of Singapore and the ... Kindly complete a hospitalisation claim form if this claim is related to pre or post

  • Published on

  • View

  • Download

Embed Size (px)


<ul><li><p>AXA INSURANCE SINGAPORE PTE LTD</p><p>8 Shenton Way #27-01 AXA Tower,</p><p>Singapore 068811</p><p>Customer Care Department #B1-01</p><p>1800 880 4888 (Within Singapore)</p><p>(65) 6880 4888 (International)</p><p>(65) 6338 2522 </p><p>http://www.axa.com.sg</p><p>Company Registration No. 196900406D</p><p>OUTPATIENT CLAIM FORMTo be completed by the Insured</p><p>*Name of Patient</p><p>*NRIC/Passport No.</p><p>*Name of Employee</p><p>*NIRC/Passport No.</p><p>*Date of Birth (DD/MM/YY) Name of Employer</p><p>*Date of Consultation (DD/MM/YY) *Policy No.</p><p>GP Consultant :$ __________________</p><p>Prescription/Treatment</p><p>Injection/Medication :$ __________________</p><p>Home Visit :$ __________________</p><p>Specialist Consultant :$ __________________ (Referral letter to be attached)</p><p>X-Ray/lab Procedure :$ __________________</p><p>Vaccination/Inoculation :$ __________________</p><p>Physio :$ __________________</p><p>Address</p><p>Email</p><p>Tel No. (Office) ________________________________________ </p><p>(Home) _________________________________________ </p><p>FOR OFFICE USE ONLY</p><p>C/N CODE</p><p>To help us expedite reimbursement , please tick the condition or illness for which you have consulted the doctor.</p><p>Please note that this is the common list of conditions; not all condition listed below are covered under the policy.</p><p>Other Illness (PLEASE SPECIFY): ________________________________________________________________ </p><p>I confirm that I am the patient or patients parent or guardian and I declare that all the particulars given above are to the best of my knowledge true</p><p>and correct. I hereby consent to and authorise the medical practitioner involved in my or the patients care to discuss and disclose treatment details,</p><p>discharge arrangements and relevant medical history with and to AXA Insurance Singapore Private Limited. I agree that a copy of this consent shall</p><p>have the validity of the original.</p><p>In connection with my and/or my dependants claims, I give consent for AXA Insurance Singapore Private Limited and AXA Life Insurance</p><p>Singapore Private Limited (collectively AXA) and their respective representatives or agents to collect, use, store, transfer and/ or disclose the</p><p>information (including that provided by sources other than myself) concerning me and/or my dependants, to or with all such persons (including any</p><p>member of the AXA Group or any third party service provider, and whether within or outside of Singapore and the Employer when claiming under a</p><p>Group Policy) for the purpose of enabling AXA and their respective representatives or agents to provide me and/or my dependants (where</p><p>applicable) with services required of an insurance provider, including the evaluating, processing, administering and/ or managing my and/or my</p><p>dependants claims or the Employers Group Policy(ies) with AXA (as the case may be), and for the purposes set out in AXAs Data Use Statement</p><p>which can be found at http://www.axa.com.sg (Purposes).</p><p>Claimants Signature (Parent's / Guardian's signature if Claimant is a Minor) Date</p><p>*Mandatory Fields</p><p> Abdominal Pain</p><p> Abscess</p><p> Allergic Reaction</p><p> Allergic rhinitis</p><p> Amenorrhea</p><p> Anemia</p><p> Anorexia</p><p> Arthritis</p><p> Asthma</p><p> Bronchitis</p><p> Burns 1 2 3</p><p> Bursitis</p><p> Cerumen Impact (Ear Wax)</p><p> Cervicitis</p><p> Chest Pain</p><p> Conjunctivitis</p><p> Constipation</p><p> COPD (COLD)</p><p> Corneal Abrasion</p><p> Cough</p><p> Dermatitis</p><p> Diabetes Mellitus</p><p> Diaper or Napkin Rash</p><p> Diarrhea</p><p> Dizziness (vertigo)</p><p> Duodenal Ulcer</p><p> Dysmenorrhea</p><p> Eczema</p><p> Epilepsy</p><p> Esophagitis</p><p> Fever-Pyrexia Unknown Origin</p><p> Foreign Body Eye</p><p> Foreign Body Throat</p><p> Gastritis</p><p> Gastroenteritis</p><p> Gout</p><p> Hemorrhoids</p><p> Headache</p><p> Hepatitis</p><p> Herpes Simplex</p><p> Herpes Zoster</p><p> Hives (Urticaria)</p><p> Hypertension, ess</p><p> Impetigo</p><p> Influenza</p><p> Insomnia</p><p> Irregular Menstrual Cycle</p><p> Irritable Bowel Syndrome</p><p> Laryngitis</p><p> Lumbago</p><p> Menometrorrhagia</p><p> Menopausal Migraine</p><p> Moniliasis</p><p> Mononucleosis</p><p> Otitis Externa</p><p> Otitis Media</p><p> Pediculosis</p><p> Pelvic Inflammatory Dis.</p><p> Peptic Ulcer</p><p> Pharyngitis</p><p> Pneumonia</p><p> Pre-Menstrual Tension</p><p> Rash</p><p> Scabies</p><p> Sinusitis Acute</p><p> Strain/Spr. Back</p><p> Tennis Elbow</p><p> Thrush</p><p> Tonsillitis</p><p> Upper Respiratory Tract Infection</p><p> Urethritis</p><p> Urinary Tract Infection</p><p> Vaginitis</p><p> Viral Infection</p><p> Wry Neck</p><p>DD MM YYYY</p></li><li><p>PROCEDURE</p><p>1. Pay the doctor first</p><p>2. To complete the diagnosis section.</p><p>3. Kindly note that for a hospitalisation or day surgery claim, you are required to complete a </p><p>hospitalisation claim form obtainable from AXA Insurance Singapore Pte Ltd.</p><p>4. Kindly complete a hospitalisation claim form if this claim is related to pre or post </p><p>hospitalisation.</p><p>5. Kindly submit a GP referral letter for specialist consultation.</p><p>6. Attach all the original bills/receipts you have paid and send them together with this Doctors </p><p>Certification to :</p><p>AXA INSURANCE SINGAPORE PTE LTD</p><p>8 Shenton Way #27-01 AXA Tower</p><p>Singapore 068811</p><p>5. To avoid unnecessary delay in assessing your claim, please state your policy/member </p><p>correctly and clearly overleaf.</p><p>Note:</p><p>Claims submitted later than 30 days after the date of treatment may be declined.</p><p>AXA/FM01/July 2014</p></li></ul>


View more >