HMO/Medical Claims

Inpatient

     o Claim Form which is duly filled and signed by:
          o Member / Insured
          o Attending physician
     o Discharge Summary / Clinical Abstract
     o Original Official Receipts (PF/Hospital Bill/Medicine)
     o Itemized and Summarized Statement of Accounts
     o Charge Slips, if any
     o Prescriptions
     o Laboratory and / or Diagnostic Request and Result
     o Police Report (if due to accident)
     o Operative Record, if with surgery

Outpatient 

     o Claim Form which is duly filled and signed by:
          o Member / Insured
          o Attending physician
     o Medical Certificate with Diagnosis
     o Original Official Receipts (PF/Hospital Bill/Medicine)
     o Charge Slips, if any
     o Prescriptions (Policies with Medicine Cover)
     o Laboratory and / or Diagnostic Request and Result
     o Police Report (if due to accident)
     o Operative Record, if with surgery

Financial Assistance 

     o Death Certificate
     o Birth Certificate
     o HMO Card
     o Certificate of Employment
     o Proof of Relationship with Beneficiary:
          o Marriage Contract (for spouse)
          o Birth Certificate (for dependent / parent)
          o Affidavit of Guardianship (for minor beneficiary)

Hospital Income 

     o Discharge Summary with Final Diagnosis
     o Statement of Account

Life 

     o Claim Form which is duly filled and signed by:
          o Beneficiary (Claimant’s Statement)
          o Attending Physician (Physician’s Statement)
     o Policy Holder’s Statement
     o Clinical Abstract / Medical Certificate
     o Clinical History (History of Present Illness)
     o Certified True Copy of Death Certificate
     o Daily Time Record
     o Certificate of Employment
     o Police Report (if due to accident)
     o Proof of Relationship with Beneficiary:
          o Birth Certificate (for dependent / parent)
          o Marriage Contract (for spouse)
          o Affidavit of Guardianship (for minor beneficiary)

Personal Accident 

     o Claim Form which is duly filled and signed by:
          o Beneficiary (Claimant’s Statement)
          o Attending Physician (Physician’s Statement)
     o Original Official Receipts (PF/Hospital Bill/Medicine)
     o Itemized and Summarized Statement of Accounts
     o Discharge Summary / Medical Certificate
     o Prescriptions
     o Laboratory and / or Diagnostic Request and Result
     o Operative Record, if with surgery
     o Incident Report
     o If due to Motor Vehicle-related accident:
          o Police Report
          o Driver's License and Vehicle Registration

AMWA 

     o Death Certificate
     o Police Report (if due to accident)
     o Clinical Abstract (for disability claims)
     o Proof of Relationship with Beneficiary:
          o Birth Certificate (for dependent / parent)
          o Marriage Contract (for spouse)
          o Affidavit of Guardianship (for minor beneficiary)
               o For Repatriation: Certification which states the reason for the termination of the migrant worker's employment issued by the Philippine Foreign Post or POLO located in the receiving county
               o For Subsistence Allowance Benefit Claims: Certification issued by the concerned Labor Attaché
               o For Settlement of Money Claims: Certified True Copy of NLRC or compromise agreement

Third Party Administration (Outpatient) 

     o Medical Certificate
     o Laboratory and Medicine Prescription
     o Official Receipts

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