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Fillable Printable Doctor Receipt

Fillable Printable Doctor Receipt

Doctor Receipt

Doctor Receipt

PATIENT DETAILS
THIS FORM MUST BE COMPLETED FOR EVERY PATIENT RECEIVING TREATMENT. PLEASE COMPLETE A SEPERATE CLAIM FORM FOR EACH VISIT AND ATTACH YOUR INVOICE FOR PROCESSING. THE
PATIENT SHOULD BE GIVEN A DUPLICATE COPY FOR THEIR RECORDS. PLEASE ATTACH DETAILED INVOICE WHERE POSSIBLE TO EXPEDITE PAYMENT. PLEASE COMPLETE FORM IN BLOCK LETTERS.
IMPORTANT: THE HERITAGE INSURANCE COMPANY KENYA WILL REJECT ILLEGIBLE OR INCOMPLETE CLAIMS
MAIN MEMBER DETAILS
MEDICAL CLAIM FORM BLUE
INVOICE NUMBER :
SERVICE PROVIDER DETAILS
NAME OF CLINIC CONSULTING PHYSICIAN
LIBERTY HEALTH PROVIDER NO TREATMENT DATE
SHOULD HOSPITALISATION HAVE BEEN REQUIRED PLEASE INDICATE DURATION OF STAY
ADMISSION DATE DISCHARGE DATE
PATIENTS DECLARATION
I HEREBY DECLARE THE ABOVE STATED TO BE TRUE AND IN ACCORDANCE WITH THE MEDICAL SCHEME RULES.
I CONFIRM THAT THE DETAILS GIVEN ABOVE ARE CORRECT, THAT THE AMOUNT CLAIMED HEREIN IS NOT CLAIMABLE FROM
ANOTHER SOURCE, AND THAT THE PATIENT IS A MEMBER OR DEPENDANT ON BLUE HEALTH INSURANCE. I AUTHORISE THE
PROVIDER OF SERVICES TO DISCLOSE THE NATURE OF ILLNESS TO BLUE FOR ITS CONFIDENTIAL USE AND I AGREE THAT
NO AWARDS WILL BE MADE FOR THIS TREATMENT UNLESS CONTRIBUTIONS ARE RECEIVED IN RESPECT OF THE PERIOD
OF TREATMENT. LIBERTY HEALTH RESERVES THE RIGHT TO RECOVER ANY AMOUNTS PAID TO PROVIDERS IN EXCESS OF
BENEFITS DIRECTLY
SIGNED __________________________________________________ DATE ____________________________
PROVIDER’S DECLARATION
I CERTIFY THAT THE ABOVE PATIENT HAS RECEIVED THE SERVICES & TREATMENT NOTED ON THIS FORM, DIAGNOSED AND ADMINISTERED BY MYSELF AND THAT THIS
CLAIM IS IN ACCORDANCE WITH MY SPECIFIED TREATMENT
SIGNED ______________________________________________ DATE
BLUE
Healthcare that works where you work
www.libertyheathblue.com
DDMMYY
PROVIDER STAMP
The Heritage Insurance Company Kenya Limited
CfC House, Mamlaka Road P.O BOX 30390 - 00100, Nairobi, Kenya
(t)254 20 278 3000 (f) 254 20 272 7800 (m)0711 039 000, 0734 101 000 (e) [email protected] (w) www.heritageinsurance.co.ke
A member of the Association of Kenyan Insurers
FIRST NAME SURNAME
MEMBER NO DEP. CODE GENDER DOB.
FIRST NAME SURNAME
EMPLOYER
MFDDMMYY
DDMMYY
DDMMYY
DDMMYY
SERVICE PROVIDEDCODEDESCRIPTION
COST
LABORATORY TESTS
OTHER DIAGNOSTIC PROCEDURES
/ TESTS
OPTICAL
DENTAL
PRESCRIBED DRUGS (ATTACH COPY
OF PRESCRIPTION)
CODEQTYDOSAGEDESCRIPTION
DIAGNOSIS CODING
DIAGNOSISCODE (TICK)DIAGNOSISCODE (TICK)DIAGNOSISCODE (TICK)DIAGNOSISCODE (TICK)
ALLERGIC RHINITISJ30C-SECTIONO82MALARIAB54PHARYNGITISJ02
ANAEMIAD64DENTAL CARIESK02MYOPIAH52PNEUMONIAJ18
ANTENATAL SCREENINGZ36DERMATITISL30
OPTICAL EXAMINATION
OF EYES AND VISIONI
Z01
SPONTANEOUS BIRTHO80
BRONCHITISJ40DIARRHOEA/GASTROA09TONSILLITISJ03
CANDIDIASISB37GASTRITISK29OTITUS MEDIAH66URTIJ06
CONJUNCTIVITISH10INFLUENZAJ10PEPTIC ULCERK27UTIN39
Other
CONSULTATION
0190 - GP0191 - SPECIALIST11001 - OPTICAL8101 - DENTALOTHERCOST
IS THIS A MATERNITY RELATED CLAIM?
Yes
No
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