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Medical Reimbursement Claim
Full Name
*
Principal's Name if Dependent
Email Address
*
Phone
*
Company Name
*
Hospital Clinic's Name
*
Type of Availment
*
Please select an option
In-Patient
Out-Patient
Teleconsultation
Other
Please Specify
*
Incident Date
*
Admission Date
*
Discharge Date
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Final Diagnosis
*
Total Amount of Claim
*
Please enclose legible copies of the following documents:
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Official Receipts or Sales Invoice (Original BIR Registered) (We don’t accept Acknowledgement Receipt & Charge Slip)*
Medical certificate to include final diagnosis (For Inpatient and Outpatient Laboratory)*
Medical abstract (If applicable)
Doctor’s order for laboratory tests/procedures*
Doctor’s prescription for outpatient medicines*
Itemized Statement of Account (inpatient/confinement)*
Police report (vehicular accident)/Affidavit of Accident (for other incidents)*
Other
Please Specify
*
Upload the copies of your documents (please take note that you must also submit the complete original copies of the requirements before we can transfer the payment to your account.)
*
Drag and Drop (or)
Choose Files
Upload (multiple files – up to 15 files, 2MB each)
Reimbursement will be sent via e-transfer
Please note that this facility has a minimum bank charge of PHP25.00 that will be taken out of your total reimbursable amount.
Bank Account Name
*
TextBank Account Number (Peso Account)
*
Bank Name
*
Submit
