Cigna Reimbursement Claim Form

Provider Name :

Patient Name :

Insurance Company : Aafiya Insurance

Patient Mobile No :

File No :

Company Name :

Member ID :

Date Of Treatment :

Date Of Birth :

Gender :

Chief Complaints :

Referral (if needed) :

Clinical Findings :

Vital Signs:

BP:

Temp:

HR:

RR:

Diagnosis:

Date of Onset :

Diagnosis :

ICD Code:

PEC/CHRONIC: CONGENITAL MATERNITY DENTAL OPTICAL WORK RELATED OTHERS

Treatment Plan :

Requested Investigations :

Estimated Cost :

Prescription

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 :
Stamp & Signature :

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.
Patient ‘s signature{Parent if minor} :

Date :