METLIFE CLAIM

MANAGED CARE CLAIM FORM

FORM No.

Patient Name:

Clinic/Hosp. No

Subscriber No:

Policy Number:

Cert. No

Dependent No

Please fill this portion to have prompt reimbursement and avoid unnecessary suspension

1 - How long has patient been suffering from this sicknes:

2 - Did patient have any previous treatment/consultation at your clinic/other medical facility for this sickness, please specify the date:

Diagnosis

Physician Request

Prescription

NB: IN CASE OF SURGERY, HOSPITALIZATION, MRI, C.T.SCAN, ECHOCARDIOGRAPHY, TREADMILL, ECHO DOPPLER OR PHYSIOTHERAPY PLEASE FILL THE " PRE-DETERMINATION APPROVAL REQUEST FORM"

Physician's Signature and Stamp

Date

Authorization Statement

I hereby authorize any doctor, hospital, or medical provider, any insurance company or any other company, institution or any other person who has any record or information about me and/or any of my family members to provide MetLife with the complete information's, including copies of their records with reference to my sickness or accident, any treatment, examination, advice, or hospitalization. Any photocopy of this authorization shall be taken as the original copy.I hereby authorize MetLife to use my mobile number at hospital record for communicating my insurance benefits related information through Short Message Service (SMS) and I hereby waive MetLife from any and all liability or claim arising out or in connection with any failure and/or error in sending and receiving the SMS.
I understand MetLife will not provide coverage in, reimburse for treatment obtained in, reimburse for services received in, or make wire transfers or any payments to the countries identified on OFAC’s sanctions list, including but not limited to payments to any financial institutions or medical providers located in a sanctioned country. Also, MetLife will not pay a claim to individuals who: i) are residing in a sanctioned country; ii) are listed on the OFAC Specially Designated Nationals (SDN) list or any other international or local sanctions list; or iii)have traveled to a sanctioned country for purposes of receiving medical, or other treatment or services, subject to the Policy and / or Supplementary contract terms and conditions Data Transfer: I hereby give MetLife unambiguous consent, to process, share, and transfer My personal data to any recipient whether inside or outside the country, including but not limited to your Headquarters in the USA, MetLife branches, affiliates, Reinsurers, business partners, professional advisers, insurance brokers and/or service providers where MetLife believe that the transfer or share, of such personal data is necessary for: (i) the performance of the Policy; (ii) assisting MetLife in the development of MetLife business and products; (iii) improving MetLife customers experience; (iv) for the compliance with the applicable laws and regulations; or (v) for the compliance with other law enforcement agencies for international sanctions and other regulations applicable to MetLife. MetLife will ensure that such recipients will have sufficient confidentiality obligations to procure the confidentiality of the personal information and provided that MetLife complies with applicable laws in respect of such processing, sharing and transferring of that personal data. For clarity, personal data means any data/information related to Insured and/or Insured’s family which might include any health, identity and financial information or contact details, disclosed to MetLife at any time.

Employee's Signature:

Date