Aafiya Claim Form

Provider Name :

Patient Name:

Insurance Co.:

Mobile No:

File No :

Company Name:

Member ID :

Date of Treatment :

DoB:

Gender :

Chief Complaint and Main Symptoms:

Referral (if needed) :

Clinical Findings:

Vital Signs:- BP:

HR:

RR:

Diagnosis:

Date of Onset :

PEC/CHRONIC

CONGENITAL

MATERNITY

DENTAL

OPTICAL

WORK RELATED OTHERS

Treatment Plan :

Requested Investigations :

Estimated Cost :

Prescription :

Estimated Cost :

MEDICAL PRACTITIONER DECLARATION: I declare that I am the patient’s medical practitioner and that the particulars given are to the best of my knowledge true and correct.
Dr's Name:

Date:

PATIENT’S DECLARATION: I hereby authorize any Healthcare provider, Insurer, Employer or other organization to release any information regarding my medical condition & history to Aafiya for purpose of determining insurance benefits.
Name & Relationship(if guardian) :

Date :