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

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AXA INSURANCE SINGAPORE PTE LTD8 Shenton Way #27-01 AXA Tower,Singapore 068811Customer Care Department #B1-011800 880 4888 (Within Singapore)(65) 6880 4888 (International)(65) 6338 2522 http://www.axa.com.sgCompany Registration No. 196900406DOUTPATIENT CLAIM FORMTo be completed by the Insured*Name of Patient*NRIC/Passport No.*Name of Employee*NIRC/Passport No.*Date of Birth (DD/MM/YY) Name of Employer*Date of Consultation (DD/MM/YY) *Policy No.GP Consultant :$ __________________Prescription/TreatmentInjection/Medication :$ __________________Home Visit :$ __________________Specialist Consultant :$ __________________ (Referral letter to be attached)X-Ray/lab Procedure :$ __________________Vaccination/Inoculation :$ __________________Physio :$ __________________AddressEmailTel No. (Office) ________________________________________ (Home) _________________________________________ FOR OFFICE USE ONLYC/N CODETo help us expedite reimbursement , please tick the condition or illness for which you have consulted the doctor.Please note that this is the common list of conditions; not all condition listed below are covered under the policy.Other Illness (PLEASE SPECIFY): ________________________________________________________________ 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 trueand correct. I hereby consent to and authorise the medical practitioner involved in my or the patients care to discuss and disclose treatment details,discharge arrangements and relevant medical history with and to AXA Insurance Singapore Private Limited. I agree that a copy of this consent shallhave the validity of the original.In connection with my and/or my dependants claims, I give consent for AXA Insurance Singapore Private Limited and AXA Life InsuranceSingapore Private Limited (collectively AXA) and their respective representatives or agents to collect, use, store, transfer and/ or disclose theinformation (including that provided by sources other than myself) concerning me and/or my dependants, to or with all such persons (including anymember of the AXA Group or any third party service provider, and whether within or outside of Singapore and the Employer when claiming under aGroup Policy) for the purpose of enabling AXA and their respective representatives or agents to provide me and/or my dependants (whereapplicable) with services required of an insurance provider, including the evaluating, processing, administering and/ or managing my and/or mydependants claims or the Employers Group Policy(ies) with AXA (as the case may be), and for the purposes set out in AXAs Data Use Statementwhich can be found at http://www.axa.com.sg (Purposes).Claimants Signature (Parent's / Guardian's signature if Claimant is a Minor) Date*Mandatory Fields Abdominal Pain Abscess Allergic Reaction Allergic rhinitis Amenorrhea Anemia Anorexia Arthritis Asthma Bronchitis Burns 1 2 3 Bursitis Cerumen Impact (Ear Wax) Cervicitis Chest Pain Conjunctivitis Constipation COPD (COLD) Corneal Abrasion Cough Dermatitis Diabetes Mellitus Diaper or Napkin Rash Diarrhea Dizziness (vertigo) Duodenal Ulcer Dysmenorrhea Eczema Epilepsy Esophagitis Fever-Pyrexia Unknown Origin Foreign Body Eye Foreign Body Throat Gastritis Gastroenteritis Gout Hemorrhoids Headache Hepatitis Herpes Simplex Herpes Zoster Hives (Urticaria) Hypertension, ess Impetigo Influenza Insomnia Irregular Menstrual Cycle Irritable Bowel Syndrome Laryngitis Lumbago Menometrorrhagia Menopausal Migraine Moniliasis Mononucleosis Otitis Externa Otitis Media Pediculosis Pelvic Inflammatory Dis. Peptic Ulcer Pharyngitis Pneumonia Pre-Menstrual Tension Rash Scabies Sinusitis Acute Strain/Spr. Back Tennis Elbow Thrush Tonsillitis Upper Respiratory Tract Infection Urethritis Urinary Tract Infection Vaginitis Viral Infection Wry NeckDD MM YYYYPROCEDURE1. Pay the doctor first2. To complete the diagnosis section.3. Kindly note that for a hospitalisation or day surgery claim, you are required to complete a hospitalisation claim form obtainable from AXA Insurance Singapore Pte Ltd.4. Kindly complete a hospitalisation claim form if this claim is related to pre or post hospitalisation.5. Kindly submit a GP referral letter for specialist consultation.6. Attach all the original bills/receipts you have paid and send them together with this Doctors Certification to :AXA INSURANCE SINGAPORE PTE LTD8 Shenton Way #27-01 AXA TowerSingapore 0688115. To avoid unnecessary delay in assessing your claim, please state your policy/member correctly and clearly overleaf.Note:Claims submitted later than 30 days after the date of treatment may be declined.AXA/FM01/July 2014

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