Ecare Claim

Print Date/Time :

Administrative

MEDICAL CLAIM FORM

Claim Ref :

Patient Name:

Service Date:

Network:

Card No:

Health Provider:

Policy Holder :

Doctor's Name :

Payer Name :

Co-Insurance :

TPA :

E CARE INTERNATIONAL MEDICAL BILLING SERVICES

CONSULT

LAB/RAD

PHARMA

ENT

MATERN

DENTAL

Procedures

Validity :

Remarks :

Gender

Date Of Birth:

Patient's Tel No:

Acute

Pre-existing and chronic

Maternity

Chief Complaint:

Duration:

Vitals:

BP:

TEMP:

HR:

RR:

Clinical Findings:

Diagnosis:

Diagnosis Code:

Date of Onset :

Requested Investigations:

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.

PATIENT’S DECLARATION :

I hereby authorize any Healthcare provider, Insurer, Employer or other organization to release any information regarding my medical condition & history for purpose of determining insurance benefits.

Dr.Name:

Stamp:

Patient's Signature(parent if minor):

Date:

Signature:

Date: