Fillable Printable Doctor Receipt

Doctor Receipt

PATIENT DETAILS

THIS FORM MUST BE COMPLETED FOR EVERY PATIENT RECEIVING TREATMENT. PLEASE COMPLETE A SEPERATE CLAIM FORM FOR EACH VISIT AND ATTACH YOUR INVOICE FOR PROCESSING. THE

PATIENT SHOULD BE GIVEN A DUPLICATE COPY FOR THEIR RECORDS. PLEASE ATTACH DETAILED INVOICE WHERE POSSIBLE TO EXPEDITE PAYMENT. PLEASE COMPLETE FORM IN BLOCK LETTERS.

IMPORTANT: THE HERITAGE INSURANCE COMPANY KENYA WILL REJECT ILLEGIBLE OR INCOMPLETE CLAIMS

MAIN MEMBER DETAILS

MEDICAL CLAIM FORM BLUE

INVOICE NUMBER :

SERVICE PROVIDER DETAILS

NAME OF CLINIC CONSULTING PHYSICIAN

LIBERTY HEALTH PROVIDER NO TREATMENT DATE

SHOULD HOSPITALISATION HAVE BEEN REQUIRED PLEASE INDICATE DURATION OF STAY

ADMISSION DATE DISCHARGE DATE

PATIENTS DECLARATION

I HEREBY DECLARE THE ABOVE STATED TO BE TRUE AND IN ACCORDANCE WITH THE MEDICAL SCHEME RULES.

I CONFIRM THAT THE DETAILS GIVEN ABOVE ARE CORRECT, THAT THE AMOUNT CLAIMED HEREIN IS NOT CLAIMABLE FROM

ANOTHER SOURCE, AND THAT THE PATIENT IS A MEMBER OR DEPENDANT ON BLUE HEALTH INSURANCE. I AUTHORISE THE

PROVIDER OF SERVICES TO DISCLOSE THE NATURE OF ILLNESS TO BLUE FOR ITS CONFIDENTIAL USE AND I AGREE THAT

NO AWARDS WILL BE MADE FOR THIS TREATMENT UNLESS CONTRIBUTIONS ARE RECEIVED IN RESPECT OF THE PERIOD

OF TREATMENT. LIBERTY HEALTH RESERVES THE RIGHT TO RECOVER ANY AMOUNTS PAID TO PROVIDERS IN EXCESS OF

BENEFITS DIRECTLY

SIGNED __________________________________________________ DATE ____________________________

PROVIDER’S DECLARATION

I CERTIFY THAT THE ABOVE PATIENT HAS RECEIVED THE SERVICES & TREATMENT NOTED ON THIS FORM, DIAGNOSED AND ADMINISTERED BY MYSELF AND THAT THIS

CLAIM IS IN ACCORDANCE WITH MY SPECIFIED TREATMENT

SIGNED ______________________________________________ DATE

BLUE

Healthcare that works where you work

www.libertyheathblue.com

D D M M Y Y

PROVIDER STAMP

The Heritage Insurance Company Kenya Limited

CfC House, Mamlaka Road P.O BOX 30390 - 00100, Nairobi, Kenya

(t) 254 20 278 3000 (f) 254 20 272 7800 (m) 0711 039 000, 0734 101 000 (e) [email protected] (w) www.heritageinsurance.co.ke

A member of the Association of Kenyan Insurers

FIRST NAME SURNAME

MEMBER NO DEP. CODE GENDER DOB.

FIRST NAME SURNAME

EMPLOYER

M F D D M M Y Y

D D M M Y Y

SERVICE PROVIDED CODE DESCRIPTION

COST

LABORATORY TESTS

OTHER DIAGNOSTIC PROCEDURES

/ TESTS

OPTICAL

DENTAL

PRESCRIBED DRUGS (ATTACH COPY

OF PRESCRIPTION)

CODE QTY DOSAGE DESCRIPTION

DIAGNOSIS CODING

DIAGNOSIS CODE (TICK) DIAGNOSIS CODE (TICK) DIAGNOSIS CODE (TICK) DIAGNOSIS CODE (TICK)

ALLERGIC RHINITIS J30 C-SECTION O82 MALARIA B54 PHARYNGITIS J02

ANAEMIA D64 DENTAL CARIES K02 MYOPIA H52 PNEUMONIA J18

ANTENATAL SCREENING Z36 DERMATITIS L30

OPTICAL EXAMINATION

OF EYES AND VISIONI

Z01

SPONTANEOUS BIRTH O80

BRONCHITIS J40 DIARRHOEA/GASTRO A09 TONSILLITIS J03

CANDIDIASIS B37 GASTRITIS K29 OTITUS MEDIA H66 URTI J06

CONJUNCTIVITIS H10 INFLUENZA J10 PEPTIC ULCER K27 UTI N39

Other

CONSULTATION

0190 - GP 0191 - SPECIALIST 11001 - OPTICAL 8101 - DENTAL OTHER COST

IS THIS A MATERNITY RELATED CLAIM?

Yes