| 1. |
Click here
to download the Reimbursement
Claim Form. Download the Acrobat
Reader to view PDF
Files. |
| 2. |
Member should fill out Part
1 of the Reimbursement Claim
form and affix signature. |
| 3. |
Request attending physician
to fill out Part II of the
form. |
| 4. |
Request Employer's HR or
Personnel Head to fill out
Part III of the form. |
| 5. |
Prepare the following supporting
documents needed to process
or evaluate your claim for
reimbursement. |
|
|
Original official receipt(s)
of Professional Fees |
|
Original
official receipt(s)
of Hospital Fees |
|
Statement
of Account from the
hospital where member/patient
was confined or treated |
|
Individual
charge slips or itemized
breakdown of charges
to support Statement
of Account |
|
For
inpatient claims, Admitting
History Report (to be
obtained from the Medical
Records Section of the
hospital where patient
was confined) |
|
Other
: For Surgical
Cases, operative record
and histopathological
report |
|
| 6. |
Submit accomplished Reimbursement
Claim Form with complete supporting
documents to Claims Department
of Prudentialife Healthcare,
Inc.- Head Office (Pasay Road). |
| 7. |
Other documents may be requested
by PHI as the need arises. |
| |
|
| *NOTE:
Filing neither acceptance
of claims reimbursement documents
with PrudentialifeCare does
not guarantee approval or
payment of the claim. |
