Print Claim Form - OPD

Claim Form

Patient Claim Form


-
print Print Form

Uploaded Claim Form - OPD

Invoices

Visit Date : 25-03-2020
# Invoice No. Ins. Company Claim Note Claimed Amt.(฿)
01 NSB7881 Aviva
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562.10 attach_file
02 BC65243 TATA AIA
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
747.29
PID_154367-V1468_Aviva.pdf PID_154367-V1468_214_Av...
03 IN32456 Aviva 9000.00
PID_154367-V1468_Aviva.pdf PID_154367-V1468_214_Av...
Income Type Catalog
Price (฿)		 Discount /
Addition (฿)		 Billable
Amount (฿)
1.1 Hospital Medical Expenses 3000.00 -35.00 2700.00
1.2 Health Professional Fees 2000.00 -40.00 1800.00
1.1.1 Drugs and Parenteral Nutrition 5000.00 -300.00 4500.00
1.1.3 Blood Transfusion Services and Blood Com... 1500.00 N/A 1350.00
1.1.5 Drugs and Parenteral Nutrition 2500.00 -250.00 2250.00
Total 14,000.00 -625.00 12,600.00
04 BC32456 TATA AIA
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
766.71
PID_154367-V1468_Aviva.pdf PID_154367-V1468_214_Av...
05 BC32456 TATA AIA
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
544.83
PID_154367-V1468_Aviva.pdf PID_154367-V1468_214_Av...

Doctor Form

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Medical Certificate

1234567
Peadiatric
20-04-2020

I am Aric Bergnaum

Doctor who has the license no. 0

Has Performed Physical Examination of Mr. Theo James,

with Patient ID 85924

Diagnosis

Diagnosis
Diarrhea
Pneumonia

Comment

Confirm that the patient has come to the hospital for OPD treatment on Date - 01-12-2020

Appropriate for the Patient to rest/recover for 30 days from 01-01-2020 to 07-01-2020

Doctor's Signature